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DIABETIC  MANUAL 


MUTUAL  USE  OF  DOCTOR  AND  PATIENT 


BY 

ELLIOTT  P._JOSLIN,  M.D. 

ASSISTANT  PROFESSOR  OF  MEDICINE,  HARVARD   MEDICAL   SCHOOL;   CONSULTING 

PHYSICIAN,  BOSTON  CITY  HOSPITAL;    COLLABORATOR   TO   THE   NUTRITION 

LABORATORY  OF  THE  CARNEGIE  INSTITUTION  OF  WASHINGTON, 

IN  boston;    MAJOR,  M.  R.  C. 


WlustrateD 


LEA   &   FEBIGER 

PHILADELPHIA  AND   NEW  YORK 

1918 


Copyright 
LEA  &  FEBIGER 

1918 


:  gc 


TO 


THE  DIABETIC  PATIENTS 

OF 

THE  UNITED   STATES  OF  AMERICA 


UPON   EACH   ONE   OF  YOU 

REST    RESPONSIBILITIES    OF   SAVING    FOOD 

BOTH  BY 

YOUR   OWN    EXAMPLE,    SHOWN    IN   THE  CAREFUL   TREATMENT 

OF  YOURSELF,   AND   BY  YOUR   INSTRUCTION    OF 

THOSE   ABOUT   YOU   IN    FOOD   VALUES 


PREFACE. 


For  one  diabetic  patient  who  knows  too  much  about  his 
disease  there  are  unquestionably  ninety-nine  who  know  too 
little.  That  is  the  reason  for  this  little  book,  in  which  I  have 
tried  to  give  in  schematic  form  the  modern  conception  of 
diabetes  and  its  treatment.  The  presentation  is  radically 
elementary,  in  the  hope  that  a  book  of  this  nature,  written 
in  the  light  of  recent  discoveries  in  laboratory  and  clinic, 
will  be  a  help  to  the  general  practitioner  and  useful  as  a 
text-book  for  his  patients,  thereby  securing  their  intelligent 
cooperation,  and  thus  enabling  him  to  raise  the  standard  of 
diabetic  treatment.  These  pages  emphatically  cannot  take 
the  place  of  a  competent  physician,  but  I  trust  that  they  will 
supply  sound  instruction  in  combating  a  disease  which  is 
statistically  four  times  as  prevalent  in  Boston  today  as  in 
1890,  and  twice  as  prevalent  in  the  registration  area  of  the 
United  States  as  in  1900. 

The  manual  is  arranged  in  four  parts.  Part  I  might  be 
called  a  diabetic  primer.  It  gives  in  untechnical  language 
a  rapid  survey  of  the  whole  subject,  sketching  fundamental 
conceptions  and  emphasizing  their  most  important  applica- 
tions. Part  II  retraces  with  more  detail  and  in  more  technical 
language  the  general  field,  and  contains  an  outline  of  the 
treatment  of  the  severer  diabetic,  already  elsewhere  described 
for  physicians  in  The  Treatment  of  Diabetes  Mellitus,  recently 
published  for  the  author  by  Messrs.  Lea  &  Febiger.     The 


vi  PREFACE 

technic  of  becoming  sugar-free  and  remaining  so  is  described 
in  detail.  Part  III  contains  diet  tables  and  recipes  which 
the  author  has  found  valuable  in  his  daily  practice.  In 
Part  IV  are  described  the  simplest  tests  which  a  physician 
can  employ  for  the  estimation  of  sugar  and  acid  bodies  in  the 
urine,  the  sugar  in  the  blood  and  the  carbon  dioxide  in  the 
alveolar  air.  These  tests  can  be  readily  acquired.  I  have 
been  teaching  them  for  several  months  to  my  most  experi- 
enced nurses,  and  if  druggists  should  master  them  I  am  sure 
they  would  be  of  great  service  to  their  respective  localities. 

Tables  and,  to  a  lesser  extent,  the  text  show  repetition. 
This  is  with  design,  and  I  trust  will  prove  to  be  with  profit. 

In  the  preparation  of  the  following  pages  I  am  indebted 
directly  or  indirectly  to  nearly  all  who  helped  me  in  the 
compilation  of  The  Treatment  of  Diabetes  Mellitus,  but  more 
than  ever  I  am  under  obligation  to  Professor  Walter  R.  Miles 
for  his  valuable  counsel  and  continuous  aid. 

I  am  especially  grateful  to  my  publishers  because  of  their 

continued    courtesies,   and   to    my   secretary,  Miss    Helen 

Leonard,  upon  whom   has   devolved   the   final   revision  of 

the  proof. 

E.  P.  J. 

Boston,  1918. 


CONTENTS. 

PART  I 
INTRODUCTION  TO  DIABETIC  TREATMENT. 

CHAPTER  I. 
General  Considerations 17 

CHAPTER  II. 
.The  Treatment  of  Mild  Cases 22 

CHAPTER  III. 
The  Improvement  in  the  Treatment 26 

CHAPTER  IV. 
Questions  and  Answers  for  Diabetic  Patients    ....       29 

CHAPTER  V. 
Diabetic  Arithmetic 34 

CHAPTER  VI. 
Efficiency  in  Visits  to  a  Doctor 45 

CHAPTER  VII. 

Hygiene  for  the  Diabetic 47 


vili  CONTENTS 

PART  II. 
THE  DETAILS  OF  DIABETIC  TREATMENT. 

CHAPTER  I. 

The  Diet  of  Normal  Individuals. 

Carbohydrate — Protein — Fat — Food  Values  and  Require- 
ments— Composition  of  Normal  Diet — Caloric  Values      51 

CHAPTER  II. 

The  Diet  of  Diabetic  Individuals. 

Normal  and  Diabetic  Diets  Compared  —  Carbohydrate- 
Protein — Fat — Liquids — Salt 65 

CHAPTER  III. 

The    Treatment  of  Moderately    Severe  and  Severe  Cases  of 

Diabetes. 

Fasting  —  Intermittent  Fasting  —  Carbohydrate,  Protein 
and  Fat  Tolerance — Reappearance  of  Sugar — Weekly 
Fast  Days — Caloric  Needs 80 

CHAPTER  IV. 
Acid  Intoxication;  Acidosis;  Diabetic  Coma 103 

CHAPTER  V. 
Weight  Peculiarities 106 

CHAPTER  VI. 
The  Diet  of  the  Untreated  Diabetic  is  Expensive      .     .     110 

CHAPTER  VII. 
Care  of  the  Teeth 113 


CONTENTS  ix 

CHAPTER  VIII. 

Care  of  the  Skin 116 

CHAPTER  IX. 
Treatment  of  Constipation 118 

CHAPTER  X. 

Drugs  in  the  Treatment  of  Diabetes 120 

PART  III. 
THE  DIABETIC.  MENU  AND  FOOD  VALUES. 

CHAPTER  I. 

Dietetic  Suggestions,  Recipes  and  Menus 121 

CHAPTER  II. 
Diet  Tables 143 

PART  IV. 

SELECTED  LABORATORY- TESTS  USEFUL  IN 
MODERN  DIABETIC  TREATMENT. 

CHAPTER  I. 
The  Examination  of  the  Urine,  Blood  and  Expired  Air  .     165 


PART  I. 
INTRODUCTION  TO  DIABETIC  TREATMENT. 


CHAPTER    I. 
GENERAL  CONSIDERATIONS. 

It  is  perfectly  true  that  diabetes  is  a  chronic  disease,  but, 
unlike  rheumatism  and  cancer,  it  is  painless;  unlike  tuber- 
culosis, it  is  clean  and  not  contagious,  and  in  contrast  to 
many  diseases  of  the  skin  it  is  not  unsightly.  Moreover,  it 
is  susceptible  to  treatment,  and  the  downward  course  of  a 
patient  can  usually  be  promptly  checked.  Treatment,  how- 
ever, is  by  diet  and  not  by  drugs,  and  the  patients  who  know 
the  most,  conditions  being  equal,  can  live  the  longest.  There 
is  no  disease  in  which  an  understanding  by  the  patient  of 
the  methods  of  treatment  avails  as  much.  Brains  count. 
But  knowledge  alone  will  not  save  the  diabetic.  This  is  a 
disease  which  tests  the  character  of  the  patient,  and  for 
success  in  withstanding  it,  in  addition  to  wisdom,  he  must 
possess  honesty,  self-control  and  courage.  Already  33  of  my 
patients  have  lived  longer  than  would  have  been  expected  of 
them  had  they  been  normal,  healthy  people.  For  the  diabetic 
this  is  a  demonstration  and  a  challenge. 

The  underlying  cause  for  diabetes  is  usually  considered 
to  be  a  derangement  in  one  of  the  functions  of  the  pancreas. 
This  is  a  gland,  in  animals  known  as  the  sweetbread,  which 
lies  behind  the  stomach  near  the  liver.  It  discharges  into  the 
bowel  the  most  important  digestive  juice  of  any  gland  in 
the  bodv,  and  this  juice  is  capable  of  digesting  all  kinds  of 
2  * 


18         INTRODUCTION  TO  DIABETIC  TREATMENT 

food.  Strangely  enough  this  digestive  action  of  the  pancreas 
remains  undisturbed  in  diabetes.  The  fault  with  the  pan- 
creas in  diabetes  concerns  that  function  of  the  gland  which 
regulates  the  body's  use  of  the  sugar  formed  from  the  food. 
This  function  appears  to  reside  in  groups  of  cells  distributed 
throughout  the  pancreas  and  called  the  "islands  of  Langer- 
hans."  When  these  cells  have  been  found  to  be  diseased  a 
history  of  diabetes  has  been  usually  demonstrable.  These 
groups  of  cells  probably  manufacture  a  special  internal 
secretion  which  is  discharged  into  the  blood.  Experimentally, 
with  animals,  it  is  easy  to  produce  diabetes  by  simply 
removing  a  large  portion  of  the  pancreas,  and  the  severity 
of  the  diabetes  so  produced  is  proportional  to  the  amount  of 
the  gland  removed.  If  the  diabetic  patient  could  secure  a  new 
pancreatic  gland  he  would  be  cured.  As  yet  all  attempts  to 
successfully  treat  diabetes  by  feeding  patients  the  healthy 
pancreatic  glands  of  animals,  by  the  use  of  extracts  made  from 
the  gland  or  by  grafting  portions  of  a  healthy  gland  under  the 
skin  have  failed.  Nevertheless,  I  expect  some  measure  of 
success  will  be  eventually  achieved  along  these  lines,  and  I 
hope  within  the  next  decade. 

Granted  that  there  is  a  natural  tendency  to  diabetes  in 
certain  individuals,  this  develops  into  the  actual  disease 
most  commonly  when  the  body  has  been  overfed.  More 
than  40  per  cent,  of  my  diabetic  cases  have  been  too  fat,  and 
in  a  recent  series  of  100  diabetic  cases  I  found  obesity  to  have 
existed  in  57  of  them.  The  average  number  of  pounds  over- 
weight for  a  series  of  457  diabetic  patients  for  different  ages 
is  shown  in  Table  1. 

Table  1. — Overweight  Usually  Precedes  Diabetes. 


Average  number  of 

Age  in  years. 

Number  of  cases. 

pounds  overweight. 

12  to  24 

38 

3 

25  to  29 

27 

54 

30  to  39 

72 

23 

39  and  over 

320 

37 

Lack  of  exercise  is  of  course  a  factor  in  producing  the  con- 
dition of  overweight,  and  thus  an  indirect  cause  of  diabetes. 


GENERAL  CONSIDERATIONS  19 

Disuse  of  the  muscles,  however,  is  itself  a  direct  factor,  for 
it  is  largely  in  these  that  the  sugar  formed  from  the  food  is 
consumed.  That  man  who  gives  up  an  active  outdoor  life 
and  is  promoted  to  an  office  chair  by  this  change  becomes  a 
promising  candidate  for  diabetes.  If  the  overfeeding  has  been 
in  the  form  of  sugar,  predisposition  to  diabetes  is  greater. 
There  is  real  danger  in  the  candy  habit.  It  is  possible  that 
the  recent  increase  in  the  quantity  of  sugar  consumed  per 
capita  in  the  United  States  has  increased  our  number  of 
diabetics.  Between  1800  and  1810  the  average  consumption 
of  sugar  by  each  individual  in  the  United  States  was  11 
pounds  a  year,  but  between  1910  and  1917  it  was  73  pounds, 
and  Mr.  Hoover  is  credited  in  the  daily  papers  for  September, 
1917,  with  showing  this  figure  for  1916  to  be  90  pounds. 

No  other  condition  rivals  obesity  in  importance  as  a  fore- 
runner of  diabetes,  but  the  strenuous  life  is  probably  of  some 
significance.  This  appears  reasonable,  for  it  has  been  shown 
that  medical  students,  after  three-hour  written  examinations 
upon  which  their  promotion  for  a  year  depends,  often  show 
sugar  in  the  urine  immediately  thereafter,  and  it  may  not  be 
a  chance  coincidence  that  within  the  last  year  I  had  at  one 
time  under  active  treatment  for  diabetes  three  children  who 
had  recently  led  their  respective  classes  at  school.  My  most 
recent  illustration  of  this  is  another  child,  Case  No.  1380,  who 
came  to  the  office  showing  6.2  per  cent,  of  sugar.  She  had 
skipped  two  classes  at  school,  and  the  following  summer  had 
eaten  even  more  than  her  habitually  large  amount  of  sweets 
and  candy. 

In  the  presence  of  an  infectious~disease,  for  example  ton- 
sillitis, an  existing  diabetes  grows  worse;  but  it  is  yet  to  be 
demonstrated  that  diabetes  frequently  occurs  as  the  result 
of  an  infection. 

Of  my  cases,  only  21  per  cent,  show  a  history  of  diabetes  in 
their  families,  i.  e.,  that  the  disease  has  been  present  in  parents, 
brothers  or  sisters.  Hereditary  cases  in  my  experience  are 
usually  mild,  and  I  am  in  hopes  that  with  the  avoidance  of 
obesity  and  with  moderation  in  the  use  of  sweet  food  the 
children  of  diabetics  may  be  no  more  liable  to  the  disease 
than  other  children.     Particularly  should  the  urines  of  such 


20         INTRODUCTION  TO  DIABETIC  TREATMENT 

individuals  be  carefully  examined  when  conditions  arise 
which  would  favor  the  development  of  diabetes.  It  would 
be  a  great  mistake  to  consider  the  diet  alone  of  importance. 
Mental  relaxation  and  physical  exercise  should  be  promoted. 
If  we  are  to  bring  about  a  decrease  of  diabetes  in  the  com- 
munity it  will  be  with  measures  such  as  these.  Every  agency 
which  promotes  health  and  physical  development  tends  to 
prevent  an  outbreak  of  the  diabetic  tendency.  "  It  is  easier 
to  keep  well  than  to  get  well."     (Greeley.) 

The  disease  sugar  diabetes,  usually  known  by  its  Latin 
name,  "diabetes  mellitus,"  is  revealed  when  sugar  is  found 
in  the  urine.  The  development  of  the  disease  may  be  gradual 
or  acute,  and  with  or  without  symptoms.  It  is  fortunate 
that  the  disease  can  be  so  readily  discovered,  for  unlike  many 
diseases  whose  beginnings  can  be  only  detected  by  specialists 
or  disclosed  by  the  help  of  elaborate  and  expensive  methods 
such  as  the  Roentgen  rays,  diabetes  can  be  easily  and  promptly 
recognized  by  any  physician  who  will  be  on  the  watch  for  it 
and  will  examine  the  urine  of  his  patient  for  sugar.  The 
subsequent  behavior  of  the  disease  and  the  effect  of  treat- 
ment are  also  easily  followed  by  simple  examinations,  and 
herein  the  diabetic  has  a  great  advantage  over  many  another 
patient. 

The  sugar  in  the  urine  of  diabetic  patients  is  derived  from 
the  food,  and  chiefly  from  that  consumed  within  the  pre- 
ceding twenty-four  hours.  The  effects  of  a  meal  begin  to 
show  by  an  increase  of  the  sugar  in  the  blood  or  by  the 
appearance  of  sugar  in  the  urine  within  ten  minutes.  Most 
of  the  sugar  in  the  urine  comes  from  carbohydrate  (sugar 
and  starch),  but  in  extremely  severe  cases  as  much  as  60 
per  cent,  of  the  protein  (examples  of  which  are  lean  of  meat 
and  fish,  white  of  egg  and  curd  of  milk)  in  the  diet  may  change 
to  sugar.  No  sugar  is  formed  from  fat,  but  if  a  diabetic  eats 
too  much  fat  he  utilizes  the  carbohydrate  and  protein  of  the 
diet  less  well. 

Improvement  in  diabetes  takes  place  when  the  urine  is 
kept  free  from  sugar.  The  annoying  symptoms  of  the  un- 
treated diabetic  then  vanish.  Under  such  conditions  the 
power  of  the  pancreas  to  assimilate  carbohydrate  is  increased. 


GENERAL  CONSIDERATIONS  21 

Conversely,  if  the  urine  is  not  free  from  sugar  the  patient  is 
generally  only  holding  his  own,  or  more  likely  is  growing 
worse.  Professor  Naunyn,  who  for  a  generation  was  perhaps 
the  leading  specialist  in  diabetes,  observed  that  even  severe 
cases  if  treated  early  did  well,  whereas  mild  cases  if  neglected 
usually  did  poorly. 

In  what  follows  an  attempt  will  be  made  to  show  how  to 
treat  the  disease,  and  since  success  of  treatment  is  most  easily 
attained  by  the  selection  of  a  diet  which  will  keep  the  urine 
sugar-free,  detailed  advice  along  dietetic  lines  will  be  given. 
The  responsibilit3r  for  maintaining  this  favorable  state  must 
rest  in  large  measure  upon  the  patient  himself.  He  must 
learn  what  diet  is  best  for  him  and  must  constantly  control 
his  condition  by  the  examination  of  his  urine.  He  is  his  own 
nurse,  doctor's  assistant  and  chemist.  If  he  tries  to  be  his 
own  doctor  he  will  come  to  grief.  To  acquire  the  requisite 
knowledge  for  this  triple  vocation  requires  diligent  study, 
but  the  prize  offered  is  worth  while,  for  it  is  nothing  less  than 
life  itself. 


CHAPTER   II. 

THE  TREATMENT  OF  MILD  CASES. 

The  present  treatment  of  mild  cases  of  diabetes  in  many 
respects  resembles  the  form  of  treatment  generally  employed 
for  all  cases  of  whatever  severity  prior  to  1913.  It  is  simple 
and  can  be  made  successful.  Patients  who  faithfully  follow 
the  advice  given  seldom  suffer  any  material  annoyance  from 
the  disease.  Even  after  a  decade  the  disease  makes  little  or 
no  progress.  How  readily  symptoms  of  thirst,  frequent 
urination  and  loss  of  weight  yield  to  treatment  is  evidenced 


Fio.   1. — The  quantity  of  sugar  daily  lost  in  the  urine  by  a  mild  but  untreated 
diabetic  patient. 

by  the  useful  careers  of  several  of  my  genial,  fat,  doctor- 
patients.  Such  a  one  is  Case  No.  653,  who  came  to  me  at 
the  age  of  fifty-three  years,  having  found  5.8  per  cent,  of 
sugar  in  the  urine.  The  volume  of  urine  in  the  entire  twenty- 
four  hours  was  3000  c.c.  (100  ounces  or  a  little  over  3  quarts). 
The  total  quantity  of  sugar  therefore  which  he  lost  and  thus 
wasted  in  the  urine  each  day  was  (3000  c.c.  X  0.058)  174 
grams  or  (Vo4)  5.8  ounces.  Fig.  1  is  an  illustration  of  this 
quantity  of  sugar,  shown  as  lumps  of  sugar,  and  is  inserted 
here  to  make  it  plain  why  any  untreated  diabetic  will  eat  more 
than  a  normal  individual  and  yet  not  be  satisfied  and  will 


TREATMENT  OF  MILD  CASES  23 

easily  lose  weight.    It  also  makes  it  evident  why  the  untreated 
diabetic  is  a  food  spendthrift. 

According  to  his  own  story  this  doctor  had  always  eaten 
freely;  candy  was  the  rule  rather  than  the  exception  in  his 
house,  and  the  hospitable  home  was  renowned  for  its  cooks. 
At  the  age  of  fifty-three  years  his  weight  was  254  pounds, 
which  for  his  height  represented  88  pounds  overweight. 
Contrary  to  the  usual  rule  he  engaged  in  athletics,  but  only 
for  a  part  of  the  year.  Despite  the  high  percentage  of  sugar 
I  could  remove  worries  at  once  and  declare  the  outlook 
favorable  because  of  the  early  detection  of  the  disease  and  the 
obviously  exciting  but  remediable  causes. 

Treatment  was  simple.  First  of  all  daily  instead  of  inter- 
mittent exercise  was  encouraged  and  temporarily  less  exact- 
ing work.  The  diet  was  likewise  rearranged.  Like  all  dia- 
betics of  whatever  severity  he  was  allowed  as  much  as  desired, 
but  controlled  by  common-sense,  of  the  following  articles: 
Water;  clear,  thin  broths;  coffee;  tea;  cocoa  shells;  cracked 
cocoa.  These  liquids  contain  practically  no  nourishment, 
and  no  allowance  need  be  made  for  the  food  content.  The 
.  balance  of  the  diet  was  made  out  for  him  in  rather  more 
definite  terms.  Thus  he  was  given  for  breakfast  two  eggs  and 
four  strips  of  bacon,  and  at  the  other  two  meals  a  single  por- 
tion of  meat  or  fish  of  moderate  size.  Here  again  the  diet 
resembles  in  quantity  that  prescribed  for  severer  cases,  for 
all  excesses  are  avoided.  The  remainder  of  the  menu  was 
made  up  of  articles  selected  from  the  following  lists  without 
limitations  as  to  quantity  or  quality,  though  he  was  restricted 
to  the  use  of  a  single  vegetable  from  the  20  per  cent,  group 
at  a  meal.    (See  Table  2;  also  p.  25.) 

It  will  be  seen  that  the  choice  of  diet  was  liberal.  It  con- 
tained nearly  everything  except  sugar,  bread,  bread  products 
and  cereals,  desserts,  milk  and  milk  products.  Even  potato, 
in  the  20  per  cent,  group,  and  fruits  were  allowed  freely. 

What  was  the  result  of  this  treatment  upon  our  fat  doctor, 
Case  No.  653?  The  next  specimen  of  urine  contained  1  per 
cent,  of  sugar,  and  as  the  quantity  of  urine  was  2040  c.c, 
the  total  excretion  was  20  grams,  or  two-thirds  of  an  ounce. 
Nine  days  later  the  percentage  of  sugar  was  0.4  and  the 


24 


INTRODUCTION  TO  DIABETIC  TREATMENT 


amount  5  grams,  and  a  week  later  the  urine  was  sugar-free. 
It  has  remained  so  since.  The  weight  of  the  patient  is  now 
213  pounds,  a  reduction  of  41  pounds.  Except  for  the  addition 
of  cream  and  butter  to  the  above  diet  no  change  in  it  was 
made  for  some  months;*  later  it  was  gradually  increased,  and 


Table  2. 


-Foods  Classified  According  to  the  Percentage 
Content  of  Carbohydrate. 


Vegetables  (fresh  or  canned). 


5  per 

cent. 

10  per  cent. 

15  per  cent. 

20  per  cent. 

Lettuce 

Tomatoes 

Pumpkin 

Green  peas 

Potatoes 

Cucumbers 

Brussels 

Turnip 

Artichokes 

Shell  beans 

Spinach 

sprouts 

Kohl-rabi 

Parsnips 

Baked  beans 

Asparagus 

Water  cress 

Squash 

Canned 

Green  corn 

Rhubarb 

Sea  kale 

Beets 

lima  beans 

Boiled  rice 

Endive 

Okra 

Carrots 

Boiled 

Marrow 

Cauliflower 

Onions 

macaroni 

Sorrel 

Egg  plant 

Mushrooms 

Sauerkraut 

Cabbage 

Beet  greens 

Radishes 

Dandelion 

Leeks 

greens 

String  beans 

Swiss  chard 

Broccoli 

Celery 

Fruits. 

Ripe  olives  (20 

per  cent,  fat) 

Oranges 

Apples 

Plums 

Grape  fruit 

Cranberries 

Pears 

Bananas 

Lemons 

Strawberries 
Blackberries 
Gooseberries 

Apricots 

Blueberries 

Cherries 

Prunes 

Peaches 

Pineapple 

Watermelon 

Currants 

Raspberries 

Huckleberries 

Nuts. 

Butternuts 

Brazil  nuts 

Almonds 

Peanuts 

Pignolias 

Black 

Walnuts 

walnuts 

(English) 

Hickory 

Beechnuts 

40  per  cent. 

Pecans 

Pistachios 

Chestnuts 

Filberts 

Pine  nuts 

Miscellaneous. 

Unsweetened 

and    unspiced 

pickle,  clams,  oysters,  scal- 

lops,  liver, 

fish   roe. 

TREATMENT  OF  MILD  CASES  25 

in  September,  1917,  in  answer  to  my  inquiry,  the  patient 
summarized  for  me  his  diet,  and  wrote  as  follows: 

Breakfast. — Oatmeal  with  cream,  2  eggs,  hash  (alter- 
native, fish  or  fish  balls),  fruit  of  any  kind  and  potatoes. 

Lunch. — Cold  meat  (alternative,  hash,  creamed  salt  fish, 
sometimes  meat  pie  made  with  pastry  or  macaroni),  potatoes 
and  fruit. 

Dinner. — Any  kind  of  soup  except  baked-bean  soup,  any 
kind  of  meat  or  fish,  all  kinds  of  vegetables  and  salads.  For 
dessert  generally  fruit,  now  and  then  a  custard  made  with  salt 
and  no  sugar  or  an  apple  pie  made  without  sugar. 

"When  at  home  I  very  rarely  eat  any  bread  of  any  kind. 
If  out  to  dinner  will  eat  bread,  occasionally  a  couple  of 
griddle  cakes  without  syrup  or  sugar,  and  now  and  then  a 
doughnut.  If  at  a  dinner  party  I  drink  whisky  or  wines. 
Have  not  tasted  a  cocktail  or  any  kind  of  malt  liquor  for  four 
years.  Average  consumption  of  alcoholic  drinks  would  be 
about  one  ounce  a  week.  Have  not  wilfully  eaten  anything 
prepared  with  sugar  for  four  years.  Have  used  100  saccharine 
pills  in  thirty-two  months.  I  cannot  say  just  how  many  days 
I  have  been  forced  to  stay  away  from  business,  but  my 
trouble  has  not  interfered  with  my  daily  life." 

The  treatment  which  this  patient  has  undergone  has  been 
the  treatment  of  most  cases  of  diabetes  of  whatever  type  in 
the  past,  but  with  this  notable  difference  in  result:  That 
upon  it  this  patient,  a  mild  case,  has  been  able  to  keep  sugar- 
free.  By  means  of  such  a  diet  even  severe  cases  often  live  for 
a  year  or  two  and  moderately  seyere  cases  for  more  than  half 
a  decade.  This  still  remains  the  diet  best  adapted  to  those 
moderately  severe  and  severe  diabetics  who  are  ignorant  or 
unwilling  to  make  an  effort  to  improve.  But  for  the  intelli- 
gent patient  with  moderately  severe  or  severe  diabetes  who 
is  honest,  energetic  and  lias  self-control,  later  pages  will  show 
how  his  span  of  life  can  be  lengthened,  his  comfort  main- 
tained and  his  efficiency  in  large  part  preserved. 


CHAPTER  III. 

THE  IMPROVEMENT  IN  THE  TREATMENT. 

One  often  hears  the  remark  that  patients  with  diabetes 
live  for  years  with  little  inconvenience  to  themselves,  even 
though  strict  rules  of  diet  are  neglected.  This  may  be  a 
consoling  thought  to  some  weak-willed  patient,  but  if  the 
average  diabetic  yields  to  such  seductive  advice  the  proba- 
bility is  overwhelming  that  he  will  later  pay  the  penalty. 
Furthermore,  such  statements  are  not  true.  Their  origin 
lies  in  the  favorable  course  of  the  large  number  of  mild  cases 
of  diabetes,  but  just  as  it  is  a  serious  blunder  in  war  to 
disparage  the  strength  of  the  enemy,  so  it  is  in  diabetes. 
How  serious  in  the  past  diabetes  has  really  been,  and  at  the 
same  time  how  much  the  methods  of  treatment  have  improved 
during  the  recent  years,  is  better  shown  by  the  statistics  for 
diabetes  of  the  Massachusetts  General  Hospital  than  in  any 
other  way  I  know.  These  statistics  are  incorporated  in 
Table  3.  No  student  of  medicine,  practitioner,  patient  or 
investigator  can  fail  to  be  impressed  by  them  or  to  gather 
hope  for  the  future  from  this  progressive  improvement.  It 
is  gratifying  that  this  advance  has  come  through  hard  work 
and  not  by  chance,  and  that  multitudes  of  scientific  men 
and  women  have  shared  in  it.  I  believe  everyone  will  agree 
that  Dr.  Frederick  M.  Allen,  of  the  Rockefeller  Institute  for 
Medical  Research,  has  contributed  most  of  all  toward  bring- 
ing this  improvement  about. 

Table  3. — The  Recent  Improvement  in  Diabetic  Treatment  as 

Shown  by  the  Statistics  op  the  Massachusetts 

General  Hospital. 


Period. 

Number  of 
cases. 

Mortality  during  hospital  stay. 
Number  of  deaths.            Per  cent. 

1824  to  1898 

172 

47 

27 

1898  to  1914 

284 

80 

28 

1914 

51 

8 

16 

1915 

89 

11 

12 

1916 

103 

8 

8 

1917 

105 

6 

6 

IMPROVEMENT  IN  THE  TREATMENT  27 

During  the  first  seventy-four  years  subsequent  to  the 
opening  of  the  hospital,  of  every  100  diabetic  patients  who 
entered  the  hospital  27  died  within  its  walls.  Even  in  the 
succeeding  period  of  sixteen  years,  which  closed  with  the  year 
1913,  the  mortality  remained  as  high.  Examination  of  the 
next  few  years  ending  with  the  present  shows  a  constant 
lowering  of  the  mortality,  so  that  in  1917  it  was  less  than 
one-fourth  of  what  it  was  a  few  years  ago.  A  reduction  in 
mortality  from  28  per  cent,  to  6  per  cent,  is  no  mean  achieve- 
ment. 

I  consider  these  figures  far  more  valuable  than  my  own, 
which  follow,  in  showing  the  improvement  in  diabetic  treat- 
ment, because  in  a  large  hospital  the  cases  cannot  be  selected, 
and  the  treatment  is  carried  out  by  many  rather  than  by  a 
single  physician.  Confirmatory  of  the  Massachusetts  General 
Hospital  statistics,  however,  are  those  of  my  own  cases 
treated  at  the  Corey  Hill  Hospital  and  the  New  England 
Deaconess  Hospital  beginning  with  January,  1913,  as  shown 
in  Table  4. 

I  attribute  the  improvement  in  my  own  series  of  cases  to 
(1)  the  introduction  of  the  newer  methods  of  treatment 
inaugurated  by  Dr.  Allen;  (2)  improved  methods  for  the 
estimation  of  acid  poisoning — that  arch  enemy  of  the  dia- 
betic; (3)  the  preliminary  omission  of  fat  prior  to  any  change 
in  diet;  (4)  the  omission  of  alkalis. 


Table  4. — Mortality   Among   Author's   Cases   Treated   at  the 

Corey  Hill  and  New  England  Deaconess  Hospitals, 

January,  1913  to  January,  1918. 


Number  of 

Mortality  during  hospital  stay. 

Year. 

cases. 

Number   of  deaths.              Per  cent. 

1913 

43 

4                                   9 

1914 

60 

3                                   5 

1915 

109 

6                                   6 

1916 

164 

8                                 5 

1917 

181 

4                                   2 

No  disease  is  known  to  me  whose  statistics  during  the 
last  three  years  show  an  advance  in  treatment  comparable 
to  that  demonstrated  in  Tables  3  and  4.  The  chief  explana- 
tion for  the  lessening  of  hospital  diabetic  mortality  is  undoub- 


28         INTRODUCTION  TO  DIABETIC  TREATMENT 

tedly  the  improved  methods  of  recognition  and  of  treatment 
of  diabetic  acid  intoxication,  which  formerly  used  so  often 
to  culminate  in  diabetic  coma  and  death.  This  has  been  one 
of  the  outgrowths  of  the  introduction  of  newer  methods  of 
treatment,  of  which  fasting  is  the  most  important. 

The  need  of  further  improvement  in  the  treatment  of  severe 
diabetes  still  exists.  This  fact  must  be  courageously  faced. 
The  prevention  of  acid  intoxication  is  an  important  victory 
yet  to  be  won.  This  will  be  borne  in  mind  in  all  that  follows 
about  treatment,  but  a  summary  of  the  nature  of  acid  poison- 
ing, its  cause  and  the  measures  now  available  to  combat 
it  will  be  found  beginning  on  page  103. 

All  too  often  in  recent  years  it  has  been  felt  that  if  the  urine 
of  a  patient  were  rendered  sugar-free  by  fasting  the  treatment 
of  the  diabetic  ended;  in  reality  it  is  hardly  begun.  The 
problem  of  diabetic  treatment  varies  so  much  that  it  is 
impracticable  to  give  dogmatic  rules,  though  I  often  do  so 
(1)  to  make  precise  in  my  own  mind  my  ideas  upon  treatment 
and  (2)  to  learn  by  experience  how  these  rules  can  be  ad- 
vantageously altered.  The  disease  covers  so  long  a  period 
of  time  that  it  is  really  necessary  for  the  moderately  severe 
and  severe  diabetic  patient  to  be  familiar  with  the  reasons 
for  treatment  and  the  methods  involved.  He  must  recognize 
the  three  varieties  of  food — carbohydrate,  protein  and  fat — 
and  he  must  have  a  clear  knowledge  of  the  nutritive  (caloric) 
values  of  these  foods.  Upon  his  acquaintance  with  the 
composition  and  quantities  of  the  foods  he  eats  depends  his 
ability  to  successfully  combat  his  disease.  Before  under- 
taking such  a  study,  and  indeed  as  an  introduction  to  it,  I 
have  inserted  the  following  four  chapters  because  the  material 
which  they  contain  applies  to  all  types  of  diabetes. 


CHAPTER   IV. 

QUESTIONS  AND  ANSWERS  FOR  DIABETIC 
PATIENTS. 

Knowledge  Essential  for  a  Diabetic. — The  treatment  of 
a  patient  with  diabetes  lasts  through  life.  Treatment  must 
therefore  be  adjusted  to  his  condition,  and  should  be  so 
arranged  that  it  can  be  continued  for  years  without  harm 
and  with  as  little  annoyance  or  interference  with  the  daily 
routine  as  is  possible.  Consequently  the  patient  must  be 
taught  the  nature  of  his  disease  and  how  to  conquer  it.  In 
the  following  questions  and  answers  an  attempt  is  made  to 
indicate  essential  features  of  the  knowledge  desirable  for  a 
diabetic  patient. 

Question  1.  Why  does  the  human  body  need  food? 

Axs.  To  furnish  heat,  repair  waste,  permit  growth  and 
exercise. 

Question  2.  Mow  may  the  many  varieties  of  food  be 
simply  classified? 

Axs.  Carbohydrate,  protein  and  fat,  also  water  and  salts. 
(Fig.  7,  page  52.) 

Question  (a)  What  is  carbohydrate? 
Axs.   It  occurs  in   many   forms,  but  examples  of   it  are 
sugar  and  starch  (pages  40  and~51). 

Question  (b)  What  is  protein? 

Axs.  It  also  occurs  in  many  forms,  but  examples  of  it  are 
lean  of  meat  and  fish,  curd  of  milk,  white  of  egg.  It  is 
present  to  a  lesser  extent  in  grains  and  vegetables  (pages  40 
and  53). 

Question  (c)  What  is  fat? 

Axs.  Oil,  butter,  lard,  the  fat  on  meat  and  fish  (pages  40 
and  54). 


30         INTRODUCTION  TO  DIABETIC  TREATMENT 

Question  3.  Should  the  diabetic  patient  know  about  foods 
and  their  relative  values? 

Ans.  It  is  of  the  utmost  importance  for  him  to  know  these 
things,  since  (a)  diabetes  is  a  condition  in  which  the  normal 
utilization  of  carbohydrate  is  impaired,  and  (b)  the  disease  is 
usually  due  to  overeating  (pages  18  and  19). 

Question  4.  What  is  the  proof  that  the  diabetic  does  not 
make  normal  use  of  the  carbohydrate  eaten? 
Ans.  The  appearance  of  sugar  in  the  urine. 

Question  5.  How  much  sugar  is  lost  in  the  urine? 

Ans.  From  a  mere  trace  to  two  pounds  in  the  twenty-four 
hours  (Frontispiece;  Fig.  15,  page  111).  The  percentage  of 
sugar  in  the  urine  may  reach  10  per  cent.,  but  rarely  exceeds 
this  figure. 

Question  6.  How  is  the  urine  tested  for  sugar? 
Ans.  In  many  ways.    The  Benedict  test  is  one  of  the  most 
reliable  (page  168;  also  Fig.  6,  page  37). 

Question  7.  Why  are  diabetics  unusually  hungry? 

Ans.  Because  they  must  eat  enough  to  sustain  life  and  in 
addition  enough  to  make  up  for  the  sugar  lost  in  the  urine 
(page  22). 

Question  8.  Why  are  diabetics  abnormally  thirsty? 
Ans.  Because  they  must  produce  enough  urine  to  dissolve 
the  sugar  and  thus  remove  it  from  the  body. 

Question  9.  What  is  the  aim  of  treatment? 
Ans.  The  improvement  of  the  condition  of  the  patient, 
which  is  best  indicated  by  urine  which  is  sugar-free. 

Question  10.  What  is  the  nature  of  the  treatment? 

Ans.  Restriction  of  the  variety  and  quantity  of  the  food 
to  such  an  extent  as  will  remove  the  sugar  from  the  urine; 
the  cultivation  of  the  simple  life  and  moderate,  regular 
exercise. 


QUESTIONS  AND  ANSWERS  FOR  DIABETICS       31 

Question  11.  Is  treatment  beneficial  ? 

Ans.  Yes.  In  the  large  majority  of  instances  it  cures 
disagreeable  symptoms;  it  prevents  dangerous  and  painful 
complications;  it  prolongs  life  and  enables  one  to  lead  an 
almost  normal  existence.  If  treatment  is  not  followed  the 
diabetes  grows  worse. 

Question  12.  How  does  the  diabetic  diet  differ  from  the 
normal  diet? 

Ans.  Usually  by  the  smaller  quantity  of  carbohydrate 
and  the  greater  quantity  of  fat  (Fig.  12,  page  65). 

Question  13.  How  can  sugar  be  removed  from  the  urine 
(or,  in  other  words,  the  patient  become  sugar-free)  ? 

Ans.  In  mild  cases  by  eating  less  and  exercising  more. 
In  moderate  cases  by  great  care  in  not  eating  a  particle  of 
unnecessary  food  and  by  reducing  the  quantity  of  carbo- 
hydrate and  protein.  In  severe  cases  by  omitting  the  fat 
from  the  diet,  by  which  the  danger  of  acid  poisoning  is  pre- 
vented, and  then  reducing  the  carbohydrate  and  protein,  or 
in  a  few  cases  by  fasting. 

Question  14.  When  the  urine  of  the  patient  is  sugar-free 
what  is  done  next? 

Ans.  A  little  carbohydrate  and  protein  are  first  given  the 
patient  and  then  fat,  meanwhile  testing  the  urine  daily  to 
determine  whether  the  total  quantity  of  food  and  the  differ- 
ent varieties  of  it  can  be  increased  without  the  return  of  sugar. 

Question  15.  What  can  a  diabetic  patient  do  for  himself 
besides  keeping  the  urine  sugar-free? 

Ans.  Be  cheerful  and  be  thankful  that  his  disease  is  not 
cancer,  tuberculosis  or  Bright's  disease,  but  a  disease  which 
his  brains  will  help  him  to  conquer.  Keep  his  skin  and  teeth 
scrupulously  clean.  Avoid  people  with  head  colds  and  sore 
throats.  Secure  a  daily  action  of  the  bowels.  Sleep  nine  or 
more  hours  at  night  and  invariably  take  at  least  half  an  hour 
off  during  the  day.  Exercise  moderately  in  the  forenoon, 
afternoon  and  evening. 


32        INTRODUCTION  TO  DIABETIC  TREATMENT 

Question  16.  What  is  the  commonest  enemy  of  the 
diabetic? 

Ans.  Acid  poisoning,  often  termed  acid  intoxication  or 
acidosis. 


Question  17.  How  can  acid  poisoning  be  prevented  ? 

Ans.  Practically  always  by  keeping  sugar-free.  If  the 
patient  feels  "sick"  and  is  in  doubt  about  acid  poisoning  he 
need  not  worry  if  he  (1)  goes  to  bed;  (2)  drinks  a  glass  of  hot 
water,  tea  or  coffee  or  clear,  thin  broth  slowly  every  hour  or 
hour  and  a  half,  or  if  nauseated  takes  the  same  quantity  of 
liquid  by  enema,  but  in  the  form  of  salt  solution  (a  level 
teaspoonful  of  salt  to  the  pint  of  water) ;  (3)  fasts;  (4)  moves 
the  bowels  by  injection ;  (5)  procures  a  nurse  or  has  someone 
to  act  as  nurse  so  that  he  is  relieved  of  all  responsibility;  and 
finally  (6)  avoids  soda  or  other  alkali. 

Question  18.  What  should  a  diabetic  weigh? 

Ans.  From  10  to  20  per  cent,  below  the  average  weight  for 
his  height  and  age.  (Table  28,  p.  106).  Why?  Because  if  the 
body  is  under  weight  it  will  not  be  necessary  to  eat  as  much  to 
maintain  weight,  and  thus  there  will  be  less  of  a  burden  of 
food  for  the  body  to  assimilate. 


Question  19.  What  is  a  calorie? 

Ans.  A  calorie  is  a  measure  of  heat,  just  as  a  gram  or  an 
ounce  is  a  measure  of  weight.  It  represents  the  quantity  of 
heat  which  is  necessary  to  raise  1  kilogram  of  water  1°  Centi- 
grade or  1  pound  of  water  4°  Fahrenheit. 

Question  20.  (a)  How  many  calories  are  produced  in  the 
body  by  the  utilization  of  1  gram  of^carbohydrate,  protein 
and  fat? 

1  gram  carbohydrate  produces  4  calories. 

1  gram  protein  produces/  4  calories. 

1  gram  fat  produces  ..  9kcalories. 


QUESTIONS  AND  ANSWERS  FOR  DIABETICS         33 

Question  (6)  How  much  food  does  a  diabetic  patient 
need  ? 

Ans.  About  25  to  30  calories  per  kilogram  body  weight  or 
12  to  14  calories  per  pound.  This  is  a  little  less  than  for  the 
ordinary  individual. 

A  diabetic  patient  at  the  beginning  of  treatment  should  be 
made  to  understand  that  he  is  taking  a  course  in  diabetes. 
For  successful  graduation  in  the  course  he  should  be  able : 

1.  To  demonstrate  how  to  test  the  urine  for  sugar  (page 
168). 

2.  To  serve  himself  with  approximate  accuracy,  without 
scales,  75  grams  of  a  5  per  cent,  vegetable  (page  39). 

3.  To  record  a  siunmary  of  his  diet  for  the  previous  day 
(page  42). 

4.  To  explain  the  quantity  of  carbohydrate  which  it  con- 
tains (page  43). 

5.  To  state  his  diet  on  his  weekly  fast  day  (page  99). 

6.  To  describe  what  he  is  to  do  if  sugar  returns  in  the 
urine  (page  97). 

•    7.  To  describe  what  he  is  to  do  if  he  has  reason  to  believe 
that  he  is  threatened  with  acid  poisoning  (pages  32  and  104). 


CHAPTER  V. 
DIABETIC  ARITHMETIC. 

A  Letter  to  a  Grammar-school  Girl. 

Dear  Freda: 

Diabetic  patients  often  get  discouraged  about  the  arith- 
metic of  their  diet,  and  it  has  occurred  to  me  that  if  I 
could  explain  it  to  you,  a  little  girl,  the  same  explanation 
should  be  simple  enough  for  grown-ups.  The  chief  difficulty 
arises  from  the  fact  that  when  the  doctors  talk  about  the 
diabetic  diet  they  speak  of  grams  and  kilograms,  cubic  centi- 
meters and  liters,  instead  of  ounces  and  pounds,  pints  and 
quarts.  The  reason  for  this  is  that  it  is  a  great  deal  more 
convenient  to  reckon  food  values  by  the  metric  system.  I 
do  not  know  of  a  doctor  who  uses  the  avoirdupois  system 
in  the  treatment  of  his  patients  and  in  his  reports  about  them 
whose  plan  of  treatment  of  his  patients  is  adopted  by  any 
other  doctor.  First  of  all  therefore  let  me  explain  the  metric 
system. 

The  unit  of  weight  in  the  metric  system  is  the  gram.  This 
is  a  small  weight,  and  if  you  will  remember  that  a  nickel, 
five  cent,  coin  weighs  exactly  5  grams  you  will  always  have  a 
correct  idea  of  it.  Six  nickels  (30  grams)  would  weigh  an 
ounce,  and  1000  grams  (200  nickels)  make  a  kilogram,  which 
is  the  weight  commonly  used  in  all  European  countries  instead 
of  our  pound.  A  kilogram  is  2.2  pounds.  It  is  better  to 
use  decimals — 2.2  pounds — than  fractions — 2\  pounds — for 
the  decimal  system,  when  you  are  thoroughly  familiar  with 
it,  is  much  easier  to  employ.  That  you  may  better  under- 
stand what  a  kilogram  really  means,  divide  your  own  weight 
in  pounds  by  2.2  and  the  result  is  your  weight  in  kilograms. 
A  shredded  wheat  biscuit  weighs  30  grams  (1  ounce)  and  so 
do  three  large  portions  of  butter  or  six  lumps  of  sugar, 


DIABETIC  ARITHMETIC 


35 


Fig.  2. — a,  teaspoon,  capacity  5  c.c;  b,  tablespoon,  capacity  15  c.c. 

or  j  ounce- 


Fig.  3. — a,  cream,  \  pint  or  237  c.c;  b,  drinking  glass,  capacity  8  ounces; 
c,  250  c.c.  graduate,  contains  ^  pint  fluid;  d,  measuring  cup,  capacity  8 
ounces. 


3G         INTRODUCTION  TO  DIABETIC  TREATMENT 

The  average  egg  weighs  00  grams  (2  ounces)  and  a  banana 
(peeled)  100  grams. 

30  grams   =  1  ounce,1 
1000  grams  =  1  kilogram  or  2.2  pounds. 


a  b  c  d 

Fig.  4. — a,  butter,  10  grams;  b,  shredded  wheat,  30  grams;  c,  Uneeda 
biscuit,  6  grams;  d,  three  10-gram  weights,  total,  30  grams. 


a  b  c  d 

Fig.  5. — a,  5-gram  weight;  b,  lump  sugar,  weight,  5  grams;  c,  5  oyster 
crackers, ^weight,  5  grams;  d,  Buffalo  5-cent  piece,  weight,  5  grams.^^ 

The  liquid  measures  used  are  cubic  centimeters  and  liters, 
and  these  are  employed  instead  of  ounces,  gills,  pints  and 

1  Actually  28.4  grams. 


DIABETIC  ARITHMETIC 


37 


quarts.  Thirty1  cubic  centimeters  make  a  fluidounce,  and 
you  know  in  your  cooking  that  it  takes  2  tablespoonfuls  of 
water  for  each  ounce,  and  that  ordinarily  3  teaspoonfuls 


Fig.  6. — 1  teaspoonful  (5  c.c.)  of  Benedict  solution  in  test-tube. 

make  a  tablespoonful.    One  thousand  cubic  centimeters  make 
one  liter,  and  this  is  a  little  more  than  a  quart. 

30  cubic  centimeters  (c.c.)  =  1  (fluid)  ounce. 

4  ounces  =  1  gill. 

4  gills  =  1  pint. 

946      "  "      2  pints  =  1  quart 

1000      "  "  =1  liter. 


The  foods  upon  which  diabetic  patients  live  are  nearly 
all  printed  in  the  lists  below  (Tables  5  and  6)  and  shown 
in  Fig.  7  as  well.  Most  of  the  foods  in  Table  5  come  under 
the  head  of  5  per  cent,  vegetables.    By  this  is  meant  that  not 


Actually  29.6. 


38 


INTRODUCTION  TO  DIABETIC  TREATMENT 


over  5  per  cent,  (or  5  grams  in  each  100  grams)  of  these  vege- 
tables may  be  counted  as  carbohydrate.     As  a  matter  of  fact, 


Table  5. 


-Foods  Arranged  Approximately  According  to  Content 
of  Carbohydrate. 


Vegetables  (fresh  or  canned). 


5  per 

cent.1 

10  per  cent.1 

15  per  cent. 

20  per  cent. 

Lettuce 

Tomatoes 

Pumpkin 

Green  peas 

Potatoes 

Cucumbers 

Brussels 

Turnip 

Artichokes 

Shell  beans 

Spinach 

sprouts 

Kohl-rabi 

Parsnips 

Baked  beans 

Asparagus 

Water  cress 

Squash 

( 'aimed 

Green  corn 

Rhubarb 

Sea  kale 

Beets 

lima  beans 

Boiled  rice 

Endive 

Okra 

Carrots 

Boiled 

Marrow 

Cauliflower 

Onions 

macaroni 

Sorrel 

Egg  plant 

Mushrooms 

Sauerkraut 

Cabbage 

Beet  greens 

Radishes 

Dandelion 

Leeks 

greens 

String  beans 

Swiss  chard 

Broccoli 

Celery 

Fruits. 

Ripe  olives  (20 

per  cent,  fat) 

Oranges 

Apples 

Plums 

Grape  fruit 

Cranberries 

Pears 

Bananas 

Lemons 

Strawberries 

Blackberries 

Gooseberries 

Peaches 

Pineapple 

Watermelon 

Apricots 

Blueberries 

Cherries 

Currants 

Raspberries 

Huckleberries 

Prunes 

Nuts. 

Butternuts 

Brazil  nuts 

Almonds 

Peanuts 

Pignolias 

Black 

Walnuts 

walnuts 

(English) 

Hickory 

Beechnuts 

40  per  cent. 

Pecans 

Pistachios 

Chestnuts 

Filberts 

Pine  nuts 

Miscellaneous. 

Unsweetened 

md     unspiced 

pickle,  clams 

,  oysters,  scal- 

lops,  liver,  fish  roe. 

1  Reckon  available  carbohydrates  in  vegetables  of  5  per  cent,  group  as 
3  per  cent.;  of  10  per  cent.,  group  as  6  per  cent. 

Water,  clear  broths,  coffee,  tea,  cocoa  shells  and  cracked  cocoa  can  be 
taken  without  allowance  for  food  content. 


DIABETIC  ARITHMETIC  39 

lettuce,  at  the  beginning  of  the  first  column,  contains  2.2  per 
cent.,  and  string  beans,  toward  the  bottom  of  the  second 
column,  occasionally  contain  as  much  as  6  per  cent,  carbohy- 
drate. The  average  percentage  of  carbohydrate  for  the  entire 
group  would  be  about  3  per  cent.,  or  1  gram  carbohydrate  for 
each  ounce  (30  grams)  of  vegetables.  A  large  saucerful  of 
a  5  percent,  vegetable  weighs  about  150  grams  and  contains 
about  5  grams  of  carbohydrate.  Another  reason  for  reckoning 
these  vegetables  at  3  per  cent,  available  carbohydrate  is  that 
when  they  are  cooked  considerable  carbohydrate  is  lost  in 
the  water  used  in  the  cooking.  The  same  thing  applies  to 
the  vegetables  in  the  10  per  cent,  column,  and  I  reckon  these 
vegetables  as  containing  G  per  cent,  carbohydrate  or  2  grams 
to  the  ounce.  In  the  15  per  cent,  and  the  20  per  cent,  vege- 
tables about  their  full  value  is  available.  Fruit,  also,  must  be 
reckoned  as  containing  the  full  quantity  of  carbohydrate 
assigned  to  it  in  the  column  in  which  it  occurs. 

Table  6. — Diet  Table  Showing  Total  Calories  and  Quantities 

in  Grams  of  Carbohydrate,  Protein  and  Fat  in 

30  Grams  (1  Ounce)  of  Various  Foods. 

30  grams  (1  ounce)  Carbohydrates,        Protein,  Fat, 

Contain  approximately.  grams.  grams.  grams.       Calorie9. 

Oatmeal,  dry  weight         ...      20.0  5.0  2  120 

Cream,  40  per  cent 1.0  1.0  12  120 

Cream,  20  per  cent 1.0  1.0  6  60 

Milk 1.5  1.0  1  20 

Brazil  nuts 2.0  5.0  20  210 

Oysters,  six 4.0  6.0  1  50 

Meat  (uncooked,  lean)     ...        0.0  6.0  3  50 

Meat  (cooked,  lean)  ....0.0  8.0  5  75 

Cheese 0.0  8.0  11  130 

Bacon 0.0      --        5.0  15  155 

Egg  (one) 0.0  6.0  6  75 

Vegetables  5  per  cent,  group      .1.0  0.5  0  6 

Vegetables  10  per  cent,  group    .2.0  0.5  0  10 

Potato 6.0  1.0  0  30 

Bread 18.0  3.0  0  90 

Butter 0.0  0.0  25  225 

Oil 0.0  0.0  30  270 

Fish,  cod,  haddock  (cooked)       .0.0  6.0  0  25 

Broth 0.0  0.7  0  3 

Small  orange  or  half  of  grape  fruit    10.0  0.0  0  40 

You  will  be  glad  that  patients  seldom  need  to  know  the 
food  values  of  more  than  the  20  foods  mentioned  in  Table  6. 


40         INTRODUCTION  TO  DIABETIC  TREATMENT 

I  advise  patients  to  buy  gram  scales,  but  as  many  house- 
holds already  have  ounce  scales,  I  have  arranged  Table  6  so 
that  the  quantity  of  carbohydrate,  protein  and  fat  in  an 
ounce,  or  30  grams,  of  food  are  placed  opposite  that  food. 
There  are  a  few  exceptions.  You  will  see  that  the  values  for 
six  oysters,  one  egg,  a  small  orange  or  half  a  small  grape  fruit 
are  given  instead  of  30  grams.  For  another  reason  I  have 
given,  in  the  first  line,  the  food  value  of  oatmeal  weighed 
dry,  because  when  oatmeal  is  cooked  the  quantity  of  water 
which  it  takes  up  is  so  variable  that  the  weight  of  cooked 
oatmeal  would  neither  be  uniform  from  day  to  day  nor 
the  same  with  different  kinds  of  oatmeal,  whereas  the  food 
values  for  the  dry  weights  of  all  kinds  of  oatmeal  remain 
approximately  the  same.    (See  Fig.  7,  p.  52.) 

THE  THREE  FOODSTUFFS. 

The  value  of  a  food  depends  upon  the  quantity  of  the 
three  food  materials — carbohydrate,  protein  and  fat — which 
it  contains. 

Carbohydrate  Foods. — By  carbohydrate  one  means  sugar 
and  starch.  With  sugar  you  are  acquainted,  and  a  pure 
starch  is  cornstarch.  Fruits  are  almost  wholly  water  and 
sugar  and  vegetables  largely  water  and  starch.  Bananas, 
when  green,  contain  nearly  20  per  cent,  starch,  but  when 
ripened  this  changes  to  sugar.  Potatoes  are  20  per  cent, 
starch.  Bread  is  about  60  per  cent,  starch,  and  the  flour 
out  of  which  it  is  made,  being  drier  than  bread,  contains 
about  70  per  cent.    Two-thirds  of  oatmeal  is  starch. 

Protein  Foods. — Protein  is  the  food  from  which  our  muscles 
and  tissues  are  made.  Examples  of  protein  are  the  lean  of 
meat  and  fish,  the  curd  of  milk  and  the  white  of  egg.  The 
yolk  contains  just  as  much  protein  as  the  white,  but  it  is 
mixed  with  fat.  Protein  is  also  found  in  grains,  and  there 
is  considerable  in  beans  and  peas,  but  very  little  in  other 
vegetables  and  almost  none  in  fruits. 

Fat  Foods. — Fat  is  found  mostly  in  the  form  of  butter, 
oil,  lard,  cream  and  the  fat  on  meat  and  fish.  Rich  cream 
contains  40  per  cent,  fat,  and  milk  may  contain  only  about 
3  per  cent. 


DIABETIC  ARITHMETIC  41 


FOOD  AND  FUEL. 


Foods  are  fuel  for  the  body,  just  as  gasoline  is  fuel  (food) 
for  an  automobile.  Man  and  automobile  depend  upon  fuel 
as  a  source  of  energy.  In  case  the  gasoline  gives  out  the 
automobile  will  stop,  but  if  the  food  gives  out  the  man  will 
not  immediately  die,  because  he  carries  a  good  deal  of  the 
fuel  stored  up  in  his  body,  first  and  chiefly  as  fat,  second,  a 
lesser  amount  in  the  form  of  protein  in  the  muscles  and 
various  tissues,  and  third,  a  little  in  the  form  of  carbohydrate 
as  animal  starch  (glycogen)  and  sugar  in  the  liver,  muscles 
and  blood.  Living  upon  this  reserve  supply  of  food  you 
will  remember  that  Prof.  Benedict's  man  at  the  Carnegie 
Laboratory  in  Boston  fasted  for  thirty-one  days. 

Just  as  one  can  measure  how  much  gasoline  is  required  for 
an  automobile  to  run  100  miles,  so  one  can  measure  how 
much  food  is  necessary  for  a  man  to  live  for  twenty-four 
hours  and  do  a  given  amount  of  work.  Small  automobiles 
require  less  gasoline  than  large  automobiles,  and  this  is 
pretty  much  true  of  individuals,  for  the  food  which  they  need 
depends  upon  their  weight.  There  are  exceptions.  Children 
require  proportionately  more  food  because  they  are  growing, 
and  old  people  require  less  because  they  are  quieter.  We  can- 
not measure  the  quantity  of  food  which  we  use  in  as  simple 
a  way  as  we  can  measure  the  fuel  gasoline  which  the  auto- 
mobile requires  because  we  depend  upon  three  kinds  of  food. 
However,  you  can  easily  see  that  if  we  know  the  food  value 
for  1  gram  each  of  the  foods,  carbohydrate,  protein  and  fat, 
and  if  we  know  how  much  of  eaclrfood  is  eaten,  we  can  then 
determine  the  total  food  value  of  the  diet  for  the  patient. 

THE  FOOD  MEASURE. 

A  food  measure  or  unit  of  food  value  has  been  determined 
for  each  of  the  three  foodstuffs,  and  it  is  known  as  the  calorie. 
By  a  calorie  is  meant  the  quantity  of  heat  which  is  necessary 
to  raise  1  kilogram  of  water  1°  Centigrade,  or  in  the  English 
system  1  pound  of  water  4°  Fahrenheit.  Experiments  have 
shown  that  1  gram  of  carbohydrate  or  of  protein  will  produce, 


42 


INTRODUCTION  TO  DIABETIC  TREATMENT 


when  used  up,  that  is,  when  burned  in  the  body,  4  calories, 
and  1  gram  of  fat,  9  calories.  A  gram  of  alcohol  produces  7 
calories.  If  you  read  over  again  what  I  have  just  written 
and  also  Table  6  it  is  not  very  difficult  to  reckon  the  values 
of  the  food  in  a  patient's  diet,  and  I  will  give  you  an  example 
of  this  in  the  following  table: 

Table  7. — The  Computation  of  the  Diet. 


Food. 

Bfres^k"    Dinner.      Supper.       Total 
Crams     Grams.       Grams.      grams. 

Carbo- 
hydrate 
Grams. 

Protein. 
Grams. 

Fat. 
Grams. 

Five  per  cent.  veg. 

Eggs  (2)     .      .      . 

Me:it,  cooked 

Fish      .      .      .      . 

Bacon 

Butter 

Cream,  20percent. 

Oatmeal    . 

100     + 
2 

15      + 
10     + 
30     + 
15 

200      +     150      =     450 

...       =          2 

60              ...       =       60 

60      =       60 

15      =       30 

10      +       10      =       30 

30      +       30      =       90 

...       =        15 

15 

"3 
10 

8 
12 
16 
12 

5 

"3 
3 

0 
12 
10 

io' 

25 

18 

1 

Totals       = 
Calories  per  gram       = 

Total  calories 

28 
4 

59 

4 

81 
9 

112    +  236   + 

729    =    1077 

111  the  first  column  is  recorded  a  Jist  of  the  different  foods 
taken  during  the  day.  Of  5  per  cent,  vegetables  you  will  see 
that  100  grams  were  given  for  breakfast,  200  for  dinner  and 
150  for  supper,  making  a  total  for  the  day  of  450  grams. 
Two  eggs  were  given  at  breakfast;  meat  was  given  at  dinner 
and  fish  at  supper,  but  a  little  bacon  appears  on  the  list  for 
both  breakfast  and  supper.  Cream  containing  20  per  cent, 
fat  was  given  at  each  meal;  oatmeal  only  at  breakfast. 
Knowing  the  total  quantity  of  each  kind  of  food  given 
during  the  day,  by  using  the  table  of  food  values  (Table  6) 
one  can  determine  the  amount  of  carbohydrate,  protein  and 
fat  for  each  given  food.  Thus,  450  grams  of  5  per  cent, 
vegetables  were  used.  Table  6  shows  that  for  each  30  grams 
(1  ounce)  of  5  per  cent,  vegetables,  there  is  1  gram1  carbo- 
hydrate and  0.5  gram  protein,  and  therefore  in  450  grams 
(15  ounces)  there  would  be  15  grams  carbohydrate  and  half 
as  many  grams  protein,  or  8  (actually  7.5). 

Two  eggs  were  given  at  breakfast.  Table  6  shows  that  the 
eggs  contain  no  carbohydrate,  but  that  each  egg  contains 

1  Arithmetically,  1.5  grams,  but  on  account  of  variation  in  vegetables 
and  in  cooking,  as  well  as  for  convenience,  reckoned  as  1  gram. 


DIABETIC  ARITHMETIC  43 

6  grams  protein  and  6  grams  fat — in  other  words,  2  eggs 
contain  12  grams  protein  and  12  grams  fat.  In  the  same 
way  you  can  reckon  the  amount  of  carbohydrate,  protein 
and  fat  in  60  grams  of  meat  (cooked),  60  grams  of  fish,  30 
grams  of  bacon,  30  grams  of  butter,  90  grams  of  20  per  cent, 
cream  (/.  e.,  cream  containing  20  per  cent,  butter  fat),  and 
15  grams  of  oatmeal.  In  Table  6  the  quantity  of  carbo- 
hydrate in  30  grams  of  oatmeal  is  given  as  20  grams— conse- 
quently, in  15  grams  of  oatmeal  there  would  be  half  as 
much,  or  10  grams  carbohydrate  and  3  (actually  2.5)  grams 
of  protein  and  1  gram  of  fat. 

The  actual  percentages  of  carbohydrate,  protein  and  fat 
in  various  other  foods  are  given  in  the  large  tables  on  pages 
144  to  164.  From  these  it  is  easy  to  calculate  the  quantity  of 
carbohydrate,  protein  and  fat  in  any  food  which  a  patient  eats 
when  the  total  quantity  of  eaten  food  is  known.  Patients 
and  nurses  somehow  are  repeatedly  confused  by  such  tables, 
forgetting  that  if  the  quantity  of  carbohydrate  in  milk  is 
5  per  cent.,  that  100  grams  of  milk  (or  in  this  case  cubic 
centimeters)  would  contain  5  grams  of  carbohydrate,  just  as 
•  5  per  cent,  interest  on  $100  for  a  year  would  be  $5.  Lobster, 
for  instance,  contains  16  per  cent,  protein,  and  therefore 
100  grams  of  lobster  contain  (100  X  0.16)  16  grams  protein. 

One  should  be  familiar  with  percentages,  because  in  this 
way  one  can  often  find  the  values  of  various  foods  which  are 
not  contained  in  the  30-gram  (1-ounce)  table.  Should  a 
patient,  for  example,  wish  to  substitute  his  8  grams  of 
protein  in  the  form  of  30  grams  of  meat  for  8  grams  protein 
in  the  form  of  lobster,  this  could  be  done  by  his  taking 
(o^e)  50  grams  of  lobster. 

The  use  of  percentages,  however,  is  employed  far  more  in 
determining  the  quantity  of  sugar  voided  in  the  urine  by 
diabetic  patients  in  the  twenty-four  hours.  If  an  individual 
voids  2000  c.c.  (cubic  centimeters)  of  urine  and  the  per- 
centage of  sugar  is  5  per  cent.,  it  is  plain  that  the  quantity 
of  sugar  lost  in  the  urine  during  the  twenty-four  hours  would 
be  2000  X  0.05  =  100  grams.  As  a  lump  of  sugar  amounts 
to  about  5  grams,  this  would  mean  that  the  equivalent  of 
20  lumps  of  sugar  were  lost  in  the  urine  in  one  day. 


44 


INTRODUCTION  TO  DIABETIC  TREATMENT 


It  is  interesting  to  compare  the  decrease  of  sugar  in  the 
urine  with  the  reduction  of  carbohydrate  in  the  diet. 

In  Table  8  it  is  to  be  seen  how  this  took  place.  It  is  true 
that  each  day  required  quite  a  little  arithmetic  on  the  part 
of  doctor  and  nurse,  but  now  you  could  construct  such  a 
table  by  yourself,  and  I  am  sure  would  do  it  far  better  than 
most  patients  twice  your  age. 


Table  8. — Illustration  of  Ambulatory  Treatment   without 

Fasting  or  Omission  of  Protein.     Case  No.  1237.     Ac;e 

at  Onset  in  September,  1915,  Thirty-nine  Years 

and  Five  Months. 


Urine. 

Diet 

n  grams. 

CD 
73 

0 
3 

Dietary  prescriptions  in  grams. 

C 

12 

Sugar. 

6 

oS 

nTlS 

bo 
a 

CO 

u 

a, 

Date, 

1917. 

d 

03 

43 

O.T3 

£  oj 

S3 

u 

o 

CM 

<o 

.s 

Per 

Total 

a 

S 

-  0) 

3  u 

c 

W 

.     . 

a 

2 

cent. 

gms. 

: 

03 

*8 
— 
o 

S3 

O 

"<3t3 

%  P. 

CD     J 

6 

03 

3 
6 

e 
o 

03 

is 

CU   o 

> 

3 

O 

£ 

fa 

o 

£ 

> 

E 

y, 

% 

V, 

eq 

ca 

o 

Fel).    17 

4000 

0 

8.4 

336 

19 

1500 

0 

2.2 

33 

54 

84 

0 

720    360 

3 

20 

1500 

0 

1.8 

27 

54 

84 

0 

7201 360, 3 

21 

1250 

0 

1.8 

23 

39 

84 

0 

142 

720  |  360 1  1J 

22 

1500 

0 

0.4 

6 

24 

M 

0 

432 

720  j  360   0 

23 

1250 

0 

0.2 

3 

21 

84 

0 

432 

720  !  360 1  0 

24 

1500 

0 

Tr. 

0 

24 

84 

0 

432 

720  '  360 1  0 

25 

1500 

0 

Tr. 

0 

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15 

567 

i39 

720  |  240   0 

90 

26 

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783 

720 i 120   0 

90 

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27 

1250 

0 

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82 

57 

937 

720  1  120   0 

90 

2 

60 

Mar.     1 

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82 

1162 

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1286 

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720    120   0     90 

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30 

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106 

1422 

720  i  120  1    I 

90 

2 

60 

30 

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9 

0 

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85 

106 

1462 

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720! 120 ' H 

90 

2 

1,(1 

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90 

13 

0 

0 

0 

54 

87 

168 

2076 

With  many  thanks  for  your  cheerful  help  in  the  care  of 
my  patients  at  the  hospital,  and  for  your  faithfulness  to  treat- 
ment at  all  times,  I  remain, 

Your  friend, 

Elliott  P.  Joslin. 


CHAPTER  VI. 

EFFICIENCY  IN  VISITS  TO  A  DOCTOR. 

Diabetic  patients  frequently  fail  to  get  the  benefit  they 
should  derive  from  a  visit  to  their  physician  because  they  do 
not  furnish  the  facts  upon  which  advice  for  further  treatment 
can  be  based.  The  physical  appearance  of  the  patient  is  by 
nt »  means  a  satisfactory  guide.  Information  must  be  furnishe*  1 
concerning  the  examination  of  the  urine  and  concerning  the 
diet.    The  efficient  cooperation  of  the  patient  is  necessary. 

1.  Information  Obtained  by  Examination  of  the  Urine. — The 
physician  should  know  whether  the  urine  of  the  patient  is 
free  from  sugar,  or,  if  present,  how  much  it  contains.  This  is 
essential  in  order  to  prescribe  the  diet  for  the  following  days. 
The  patient  should  therefore  take  with  him  a  specimen  of  the 
urine  saved  from  the  entire  twenty-four-hour  amount.  To 
collect  such  a  specimen  of  urine,  discard  that  voided  at 
7  a.m.,  and  then  save  all  urine  passed  up  to  and  including  that 

•obtained  at  7  the  next  morning.  Take  one-half  pint  of  the 
thoroughly  mixed  twenty-four-hour  quantity  for  examina- 
tion. Record  the  twenty-four-hour  amount  of  urine  and  the 
name  on  the  bottle.  The  bottle  in  which  the  urine  is  being 
collected  should  be  kept  in  a  cool  place.  It  is  best  to  procure 
a  bottle1  for  this  special  purpose  sufficiently  large  to  hold  the 
entire  twenty-four-hour  amount  of  urine.  Select  a  bottle 
with  a  large  mouth,  that  it  may_be  more  easily  cleansed. 
The  bottle  should  be  scalded  out  daily.  It  should  have  a 
tight-fitting  cork.  Urine  so  collected  decomposes  slowly. 
On  account  of  the  presence  of  sugar,  diabetic  urines  are  prone 
to  ferment,  and  if  fermentation  occurs  a  portion  of  the  sugar 
disappears  and  invalidates  any  subsequent  test  for  the  quan- 
tity of  sugar  which  the  urine  contained  when  voided. 

2.  Information  Obtained  by  Examination  of  the  Diet. — The 
quality  and  quantity  of  the  food  eaten  during  the  twenty-four 
hours  of  the  collection  of  the  urine  should  be  recorded.  If 
thirty  minutes  are  allowed  for  a  visit  to  the  physician's  office 

1  Bottles,  known  to  the  druggists  as  percolator  bottles,  and  graduated  in 
100  c.c.  up  to  2000  c.c.  are  most  convenient. 


46         INTRODUCTION  TO  DIABETIC  TREATMENT 

it  is  no  exaggeration  to  say  that  unless  this  recording  of  the 
diet  is  neatly  done,  one-third  to  one-half  of  the  visit  is  spent 
by  the  physician  in  learning  what  the  patient  has  eaten.  For 
this  reason  my  intelligent  patients  always  bring  a  diet  list 
arranged  according  to  the  plan  shown  in  Table  7  (page  42). 

Even  if  the  quantity  of  carbohydrate,  protein,  fat  and 
calories  are  not  worked  out  by  the  patient,  the  grouping 
together  of  5  per  cent,  vegetables,  the  summary  of  the  total 
quantity  of  butter,  cream,  meat,  eggs,  fish,  oatmeal  and  fruit, 
rather  than  the  hit-or-miss  record  of  the  amount  taken  at 
each  meal,  saves  really  an  enormous  amount  of  time,  and  time 
which  can  be  used  by  the  physician  in  helpful  advice.  In 
other  words,  the  patient  should  go  to  the  physician  for  treat- 
ment rather  than  for  a  lesson  in  grammar-school  arithmetic. 

3.  Body  Weight. — If  the  patient  has  scales,  the  weight 
fasting  and  preferably  undressed  on  the  morning  of  the 
visit  should  be  taken. 

4.  Note  Book. — The  patient  should  have  a  note  book,  and 
all  questions  about  symptoms  and  diet  which  have  arisen 
since  the  former  visit  should  be  neatly  set  down,  with  space 
left  for  an  answer  to  each  question.  It  is  a  common  error  for 
patients  to  ask  the  same  question  many  times,  whereas  if  the 
answer  is  written  down  by  the  physician  the  question  would 
thus  be  answered  once  for  all  time.  Furthermore,  it  is  a 
great  advantage  for  a  patient  to  keep  a  note  book,  because 
gradually  it  becomes  valuable  for  reference,  and  his  whole 
plan  of  treatment  is  systematized. 

The  note  book  should  contain  a  statement  as  to  whether 
sugar  has  been  present  or  absent  in  the  urine  since  the  last 
report  to  the  physician.  Such  data  can  easily  be  gathered  on 
one  page  and  again  thus  save  time.  When  a  patient  comes  to 
my  office  with  a  single  specimen  of  urine  instead  of  a  portion 
taken  from  the  twenty-four-hour  quantity,  and  without  any 
record  of  the  food  eaten  during  the  preceding  day,  and  starts 
in  to  recount  that  he  had  nothing  but  eggs,  meat  and  fish, 
then  later  remembers  that  he  had  a  little  cream  and  various 
vegetables,  then  with  prompting  recalls  butter  and  an  orange 
and  a  little  oatmeal,  I  always  pity  him,  and  on  very  excep- 
tional occasions  am  able  to  recall  with  satisfaction  after  the 
interview  Solomon's  soliloquy  in  Proverbs  xvi,  verse  32. 


CHAPTER  VII. 

HYGIENE  FOR  THE  DIABETIC. 

Any  agency  which  promotes  physical  or  mental  hygiene 
is  a  step  toward  the  prevention  of  diabetes  in  the  predisposed 
and  the  abatement  of  its  severity  when  it  has  appeared.  It  is 
only  justice  to  Hodgson  to  say  that  for  years  in  dealing  with 
his  patients  he  has  urged  that  they  "  should  be  kept  mentally 
indolent  and  physically  active."  The  experiments  of  Cannon, 
Folin  and  their  associates  upon  the  appearance  of  sugar  in  the 
urine  of  animals  and  of  both  normal  and  insane  individuals 
following  periods  of  great  emotional  excitement  have  demon- 
strated the  truth  of  the  former  half  of  the  motto.  Therefore 
all  individuals  who  have  a  tendency  toward  diabetes  should 
be  especially  urged  to  take  vacations,  and  the  good  effect 
of  vacations  should  be  generally  pointed  out.  I  have  never 
forgotten  the  remark  of  Dr.  Sabine,  of  Brookline,  that  in  the 
course  of  his  long  practice  he  had  observed  that  those  of  his 
patients  who  had  taken  active  camping  trips  in  the  woods 
bore  the  stress  of  modern  life  best.  By  this  means  exercise 
was  combined  with  mental  relaxation.  That  the  good  effects 
of  each  last  for  months  is  not  hard  to  believe.  It  is  only 
natural  to  conclude  that  if  the  muscles,  in  which  is  stored 
one-half  of  the  carbohydrate  of  the  body,  are  kept  in  good 
condition  by  training,  a  favorable  effect  must  be  exercised 
upon  the  general  metabolism  of  carbohydrate.  Pedometers 
are  to  be  encouraged.  It  is  better  to  discuss  how  far  you 
have  walked  than  how  little  you  have  eaten.  Stimulated 
by  Dr.  Allen  I  have  gradually  increased  the  exercise  of 
all  my  patients,  except  those  unduly  weak  or  in  a  dangerous 
condition  upon  entrance  to  the  hospital.  The  effect  of  this 
increase  of  exercise  upon  the  well-being  of  fat  diabetics  has 
been  pronounced,  and  it  is  striking  how  many  miles  a  semi- 


48         INTRODUCTION  TO  DIABETIC  TREATMENT 

ill  or  obese  diabetic  patient  can  learn  to  walk  during  two 
weeks.  The  patients  are  encouraged  to  take  their  walks 
soon  after  meals  and  to  go  outdoors  at  least  five  times  in 
the  day.  Not  alone  are  the  good  effects  of  exercise  shown 
by  freedom  of  the  urine  from  sugar  with  an  increased 
carbohydrate  tolerance,  but  by  improved  circulation  and 
general  well-being.  Even  fasting  diabetics,  as  a  rule,  appear 
to  do  better  when  up  and  about  the  wards  for  a  few  hours  a 
day  than  when  abed.  However,  caution  is  necessary  in  sug- 
gesting this  plan  to  severe  cases  of  diabetes.  No  ease  should 
be  considered  too  far  advanced  for  an  attempt  at  muscular 
redevelopment.  I  have  seen  two  patients  so  weak  from 
lowered  vitality  that  they  could  not  stand,  through  the 
help  of  skilful  massage  and  carefully  planned  dietetic  treat- 
ment again  begin  to  walk. 

If  the  patient,  by  means  of  exercise,  can  have  5  grams  more 
of  carbohydrate  a  day  the  added  comfort  will  be  enormous,  for 
the  addition  of  5  grams  of  carbohydrate  to  a  diet  in  a  case  of 
severe  diabetes  brings  almost  untold  joy.  It  allows  various 
alternatives,  such  as  half  a  small  orange,  50  grams  of  straw- 
berries, a  small  tablespoonful  of  cooked  oatmeal  or  a  potato 
half  the  size  of  a  pullet's  egg. 

Case  No.  1024,  a  lady,  aged  seventy-eight  years,  I  learned 
from  Miss  Walker,  her  nurse,  not  only  takes  exercise  in  the 
forenoon  and  afternoon,  but  goes  out  for  her  walk  in  the 
evening  with  a  flash  light. 

Case  No.  804,  a  patient  whose  diabetes  has  changed  from 
severe  to  moderate,  and  finally  from  moderate  to  mild  under 
his  own  care  at  home,  writes  me  that  lie  considers  exercise 
of  the  greatest  importance.  He  says  that  he  has  the  best 
garden  of  anyone  in  his  city. 

Case  No.  352,  a  diabetic  who  has  outlived  his  expectation 
of  life,  is  now  seventy  years  of  age,  having  had  diabetes 
twenty-three  years,  and  throughout  this  time  has  led  a  most 
active  life.    He  writes: 

"First,  it  is  very  hard  to  start  the  exercise,  and  the  less 
one  feels  inclined  to  start  the  more  one  needs  it.  Second, 
it  is  neither  necessary  nor  desirable  that  it  should  be  violent. 
I  found  a  quiet  ride  of  an  hour,  walking  or  jogging  after  taking 


HYGIENE  FOR  THE  DIABETIC  49 

something  on  the  stomach,  started  up  my  old  metabolism  for 
the  whole  day.    If  I  rode  hard  I  got  tired  out." 

Finally,  it  is  astonishing  how  much  exercise  a  diabetic  in 
training  can  take.  One  of  my  severe  cases,  living  on  a  strict 
diet,  several  years  ago  walked  between  twenty  and  thirty 
miles  in  one  day.  Inquiry  elicited  the  following  letter  from 
Case  No.  783,  a  Harvard  student,  who  frequently  shows  a 
small  trace  of  sugar,  a  case  which  borders  upon  the  renal 
type  of  diabetes.  The  blood  sugar  one  morning  before  break- 
fast was  0.07  per  cent.: 

Cambridge,  Mass.,  Dec.  1,  1915. 

"My  Dear  Doctor  Joslin: 

"I  first  noticed  the  effect  of  exercise  last  spring.  I  was 
rowing  for  exercise  at  the  time,  and  observed  that  if  I  went 
out  on  the  river  about  a  half-hour  after  lunch  and  rowed  for 
an  hour  or  less  the  test  would  not  show  any  sugar  in  the 
urine  at  any  time  during  the  afternoon,  even  though  I  ate 
potatoes  and  a  small  amount  of  bread  for  lunch.  But  if  I 
ate  potatoes  (no  bread)  without  so  exercising  the  test  always 
showed  sugar  about  two  hours  after  the  meal." 

Rest  is  essential.  A  tired  child  is  put  to  bed  and  wakens 
refreshed;  one  of  the  most  noted  surgeons  in  our  country 
is  not  ashamed  to  leave  his  guests  at  the  table  and  lie  down  for 
fifteen  minutes  after  his  luncheon;  the  best  treatment  for  a 
failing  heart  is  to  put  its  owner  in  bed  for  a  week.  Diabetic 
patients  should  rest  often,  should  never  get  tired  and  should 
avoid  athletic  contests.  The  diet  is  designed  to  give  a  rest 
to  the  pancreas.  Sleep  nine  hours  and  more  if  you  can,  and 
get  another  hour  of  rest  by  day.  Short  periods  of  complete 
relaxation  yield  maximal  returns. 

Forget  you  have  diabetes  and  do  not  talk  about  it  with 
others.  This  is  one  reason  for  not  using  saccharin,  and 
another  is  to  avoid  the  perpetuation  of  a  sweet  taste,  thus 
reviving  the  thought  of  the  previously  unrestricted  diet. 

Mental  diversion   is  desirable,   but  anxiety   is  harmful. 

Heavy  responsibilities  should  be  avoided  as  well  as  nervous 

upsets  and  emotional  excitements.    It  is  almost  as  dangerous 

for  a  diabetic  to  get  angry  as  for  a  man  with  angina  pectoris. 

4 


50         INTRODUCTION  TO  DIABETIC  TREATMENT 

Case  No.  1157  had  been  sugar-free  for  five  days,  but  it  came 
back  when  he  had  an  important  conference  with  one  of  his 
superintendents. 

Wear  warm  clothes  instead  of  staying  by  the  radiator  or  in 
an  overheated  room. 

The  change  in  the  mental  attitude  of  patients  during  the 
course  of  treatment  is  a  gratifying  encouragement  to  the 
physician.  Untreated  diabetics  after  a  moderate  number  of 
years  usually  show  depression,  and  with  women  this  often 
becomes  pronounced.  In  the  first  ten  years  of  my  experience 
with  diabetes  I  was  much  impressed  with  the  tendency  of  such 
patients  to  cry,  but  even  then,  with  the  methods  in  vogue, 
it  was  interesting  to  see  how  depression  disappeared  with  the 
decrease  or  disappearance  of  sugar  in  the  urine.  This  could  not 
be  explained  by  the  mental  encouragement  which  a  patient 
derived  from  his  knowledge  of  the  decrease  in  sugar  excretion. 
Even  when  patients  became  sugar-free  but  developed  acidosis, 
mental  symptoms  often  improved,  and  to  so  great  an  extent 
that  one  could  say  that  with  treatment,  even  though  it  did 
end  in  coma,  the  patient  enjoyed  life  far  more  thoroughly 
than  when  untreated.  During  the  last  two  years  and  a  half 
the  mental  attitude  of  the  patients  has  improved  still  more. 
The  enthusiasm  about  new  methods  of  treatment  has  been  so 
great  as  to  account  partially  for  this,  but  the  actual  improve- 
ment in  health  which  the  patients  have  felt  has  been  of  more 
importance.  Greeley  explained  to  my  patients  how  diabetes 
has  largely  been  robbed  of  its  terrors.  He  urged  the  simple 
life  as  a  great  aid  in  treatment  and  told  them  not  to  try  to  be 
first  in  the  Iberian  village  and  be  ill,  but  rather  to  be  second 
in  Rome  and  keep  well.  He  told  them  to  have  a  hobby,  and 
not  to  make  it  a  labor;  to  be  cheerful  and  to  keep  their  minds 
occupied,  and,  so  far  as  possible,  to  continue  the  previous 
currents  of  their  lives. 


PART  II. 
THE  DETAILS  OF  DIABETIC  TREATMENT. 

CHAPTER  I. 
THE  DIET  OF  NORMAL  INDIVIDUALS. 

The  diet  of  the  normal  individual  is  made  up  chiefly  of 
carbohydrate,  and  to  a  lesser  extent  of  protein  and  fat. 

Carbohydrate  in  the  Normal  Diet. — The  carbohydrate  foods 
are  divided  into  starches  and  sugars.  Everyone  is  familiar 
with  the  conversion  of  starch  into  sugar,  as  in  the  ripening 
Of  a  banana.  In  the  body  this  is  the  common  event,  and  is 
brought  about  through  the  activity  of  the  digestive  glands. 
Carbohydrate  is  found  chiefly  in  the  vegetable  kingdom,  as  in 
cereals,  sugar-cane,  vegetables  and  fruits.  Milk  contains 
5  per  cent,  of  sugar.  Meat,  fish  and  eggs  are  entirely  free 
from  carbohydrate  save  for  an  extremely  small  percentage 
of  animal  starch  (glycogen)  to  be  found  in  liver.  By  a  carbo- 
hydrate-free diet,  therefore,  one  usually  means  a  diet  consist- 
ing of  meat,  fish,  eggs  and  pure  fat  (such  as  butter  and  oil), 
broths,  coffee  and  tea. 

The  quantity  of  carbohydrate  in  various  foods  is  shown  in 
Fig.  7  graphically,  p.  52  and  in  Table  9.  Under  the  heading 
5  per  cent,  are  placed  foods  which  contain  not  over  5  per  cent, 
carbohydrate;  in  the  10  per  cent,  group  those  which  contain 
5  to  10  per  cent,  carbohydrate;  in  the  15  per  cent,  and  20 
per  cent,  groups  those  with  about  15  and  20  per  cent,  carbo- 
hydrate respectively.  The  foods  in  each  group  are  also 
arranged  according  to  the  amount  of  carbohydrate  which 


52 


DETAILS  OF  DIABETIC  TREATMENT 


they  contain.  Thus,  lettuce,  at  the  beginning  of  the  list, 
contains  about  2  per  cent,  carbohydrate,  and  string  beans 
toward  the  end  of  the  second  column,  about  0  per  cent.    For 


5                   10                   15                  20                   25                  30 

CALORIES 

OATMEAL 

CREAM  40# 

CREAM  205! 

MILK 

BRAZIL  NUTS 

OvSTERS  6 

MEAT  UNCOOKED 

MEAT  COOKED 

CHEESE 

BACON 

EGG-ONE 

VEGETABLES  551 

VEGETABLES   10^4 

POTATO 

BREAD 

BUTTER 

OIL 

COD,  HADDOCK 

BROTH 

.„,,  ,    (ORANGE  OH 
SMALL  {^GRAPEFR. 

- 

120 

120 

GO 

20 

210 

50 

50 

75 

130 

155 

75 

6 

10 

30 

90 

225 

270 

25 

3 

40 

mm 

u 

i    i  mmmm 

^\ 

'mmmmmm 

r  I  i  i  r  i  .> , !  ;  ■  i.l 

m^mmmmmmmm 

msmm%%mwz%m\ 

1 

i 

m 

A    '    I   )    \    1    !    : 

^ 

1  1 

^ta 

- 

- 

I 

CARBOHYDRATE   (SUGAR  AND  STARCH)}            j                                                        VTZ-m 
PROTEIN    (LEAN  OF  MEAT  AND  FISH,  CURD  OF  MILK,   EGG-WHITE  ETC. '; gjjlll 

Fig.  7. — Diet  table  showing  total  calories  and  quantities  in  grams  of 
carbohydrate,  protein  and  fat  in  30  grams  (1  ounce)  of  various  foods.  Each 
lineal  division  represents  1  gram. 

this  reason,  and  also  because  a  portion  of  carbohydrate  is 
often  lost  in  the  cooking  or  is  present  in  the  form  of  cellulose 
which  is  unassimilable,  one  may  reckon  the  average  per- 


DIET  OF  NORMAL  INDIVIDUALS 


53 


centage  of  carbohydrate  in  a  mixture  of  5  per  cent,  vegetables 
as  3  per  cent.,  and  similarly  a  mixture  of  10  per  cent,  vege- 
tables as  6  per  cent.  The  carbohydrate  in  the  15  and  20  per 
cent,  groups  should  be  taken  at  its  full  value. 

Table  9. — Foods    Arranged    Approximately    According    to 
Content  of  Carbohydrates. 

Vegetables  (fresh  or  canned). 


5  per 

cent. 

10  per  cent. 

15  per  cent. 

20  per  cent. 

Lettuce 

Tomatoes 

Pumpkin 

Green  peas 

Potatoes 

Cucumbers 

Brussels 

Turnip 

Artichokes 

Shell  beans 

Spinach 

sprouts 

Kohl-rabi 

Parsnips 

Baked  beans 

Asparagus 

Water  cress 

Squash 

Canned 

Green  corn 

Rhubarb 

Sea  kale 

Beets 

lima  beans 

Boiled  lire 

Endive 

Okra 

Carrots 

Boiled 

Marrow 

Cauliflower 

Onions 

macaroni 

Sorrel 

Egg  plant 

Mushrooms 

Sauerkraut 

Cabbage 

Beet  greens 

Radishes 

Dandelion 

Leeks 

greens 

String  beans 

Swiss  chard 

Broccoli 

Celery 

Fruits. 

Ripe  olives  (20 

per  cent,  fat) 

Oranges 

Apples 

Plums 

Grape  fruit 

Cranberries 

Pears 

Bananas 

Lemons 

Strawberries 

Blackberries 

Gooseberries 

Peaches 

Pineapples 

Watermelon 

Apricots 

Blueberries 

Cherries 

Currants 

Raspberries 

Huckleberries 

Prunes 

Nuts. 

Butternuts 

Brazil  nuts 

Almonds 

Peanuts 

Pignolias 

Black 

Walnuts 

walnuts 

(English) 

Hickory 

Beechnuts 

40  per  cent. 

Pecans 

Pistachios 

Chestnuts 

Filberts 

Pine  nuts 

Miscellaneous. 

Unsweetened 

and    unspiced 

pickle,  clams 

,  oysters,  scal- 

lops,  liver,  fish  roe. 

Protein  in  the  Normal  Diet. — Protein  is  an  essential  constit- 
uent of  the  diet,  for  out  of  protein  the  cells  and  tissues  of 


54  DETAILS  OF  DIABETIC  TREATMENT 

the  body  are  formed.  Examples  of  protein  are  the  white  of 
egg,  lean  of  meat  or  fish  and  curd  of  milk.  White  of  egg  is 
pure  protein  and  water.  In  the  white  of  one  egg  are  3  grams 
protein,  and  the  yolk  contains  an  equivalent  quantity, 
combined,  however,  with  6  grams  of  fat. 

Table  10. — The  Quantity  of  Carbohydrate,   Protein  and  Fat 

and  the  Caloric  Value  of  Thirty  Grams  (One  Ounce) 

of  Foods  in  Common  Use. 

30  grams  (1  ounce)  Carbohydrates,       Protein,  Fat, 

Contain  approximately.  grams.  grams.  grams.        Calories. 

Oatmeal,  dry  weight        ...     20.0  5.0  2  120 

Cream,  40  per  cent 1.0  1.0  12  120 

Cream,  20  per  cent 1.0  1.0  6  60 

Milk 1.5  1.0  1  20 

Brazil  nuts 2.0  5.0  20  210 

Oysters,  six 4.0  6.0  1  50 

Meat  (uncooked,  lean)     ...0.0  6.0.  3  50 

Meat  (cooked,  lean)  .      ...       0.0  8.0  5  75 

Bacon '   .      .       0.0  5.0  15  155 

Cheese 0.0  8.0  11  130 

Egg  (one)  . 0.0  6.0  6  75 

Vegetables  5  per  cent,  group      .1.0  0.5  0  6 

Vegetables  10  per  cent,  group    .2.0  0.5  0  10 

Potato 6.0  1.0  0  30 

Bread 18.0  3.0  0  90 

Butter 0.0  0.0  25  225 

Oil 0.0  0.0  30  270 

Fish,  cod,  haddock  (cooked)       .0.0  6.0  0  25 

Broth 0.0  0.7  0  3 

Small  orange  or  half  of  grape  fruit    10.0  0.0  0  40 

Table  10  contains  a  list  of  foods  which  I  have  found  most 
commonly  eaten  by  diabetic  patients  and,  indeed,  by  normal 
individuals.  Anyone  who  masters  this  table  will  know  the 
essentials  of  the  diabetic  diet.  It  is  well  worth  while  to  study 
carefully  both  Fig.  7  and  Table  10  here  numerically  compiled. 

Fat  in  the  Normal  Diet. — Fat  and  carbohydrate  are  to 
a  large  extent  interchangeable.  In  northern  climates  fat 
forms  a  large  part  of  the  diet  while  in  the  tropics  it  is  replaced 
by  an  excess  of  carbohydrate.  Examples  of  fat  in  its  pure 
form  are  oil  and  lard.  Butter  and  the  substitutes  for  it 
contain  85  per  cent,  or  more  fat.  Common  cheese  is  one- 
third  fat.  The  fat  in  meat  varies  from  that  in  fat  bacon,  in 
which  the  percentage  occasionally  rises  to  80,  to  chicken, 


DIET  OF  NORMAL  INDIVIDUALS 


55 


in  which  the  percentage  of  fat  is  3  or  less.    In  codfish  and 

haddock  the  amount  of  fat  is  negligible,  but  in  salmon  it 

reaches  13  per  cent.    Nuts  are  rich  in  fat. 

Food   Values    and   Food    Requirements. — The   quantity   of 

food  which  an  individual  requires  has  been  estimated  in 

various  ways.    One  method  has  been  to  weigh  the  amount 

of  food  eaten  by  a  large  number  of  individuals  and  then 

calculate   the   amount   consumed   by   each    individual.     I 

imagine  that  it  is  upon  this  basis  to  a  considerable  extent 

that  soldiers  are  assigned  their  rations.     The  rations  now 

furnished  the  soldiers  in  various  armies  are  reported  to  be 

as  follows: 

Table  11. — Soldiers'  Rations. 

Carbo- 
hydrate, 
grams. 

United  States  garrison  ration     .      .  651 

Russian  ration  in   Manchurian  war  487 

British  ration 524 

Italian  ration1 560 

French  ration  (normal)    ....  402 

The  rations  allowed  for  prisoners  in  the  German  prisoner- 
of-war  camps  in  the  period  prior  to  the  stringency  in  food- 
stuffs and  in  a  later  period  of  stringency  are  given  below.2 
In  general,  one  can  be  quite  sure  that  the  prisoners  were  not 
allowed  more  than  the  civil  population. 

Table  12. — Rations  Allowed  in  German  Prisoner-of-war  Camps. 


Protein, 

Fat, 

grams. 

grams. 

Calories, 

185 

141 

4751 

215 

90 

3717 

224 

195 

4962 

145 

93 

3745 

130 

117 

3478 

Carbo- 
hydrate, 
grams. 

Protein, 
grams. 

Fat, 
grams. 

Calories, 

510~ 

89 

30 

2740 

310 

57 

21 

1720 

Daily  diet  prior  to  stringency 
Daily  diet  during  stringency 

Another  method  allows  the  food  required  by  a  given  indi- 
vidual to  be  calculated  far  more  accurately.  By  this  method 
the  heat  given  off  by  a  man  at  rest  or  at  work  has  been 
determined.  The  quantity  of  food  is  then  estimated  which  is 
required  in  the  course  of  its  oxidation  in  the  body  to  produce 
an  equivalent  amount  of  heat.  The  heat  liberated  in  the 
oxidation  of  the  various  foodstuffs  has  been  determined  and 


1  From  unofficial  sources. 

2  Taylor,  A.  E.:  Jour.  Am.  Med.  Assn.,  1917,  lxix,  p.  1575. 


56  DETAILS  OF  DIABETIC  TREATMENT 

is  measured  in  heat  units  known  as  calories.  A  calorie 
represents  the  heat  which  is  necessary  to  raise  1  kilogram  of 
water  1°  Centigrade,  or  4  pounds  of  water  1°  Fahrenheit. 
For  each  kilogram  (2.2  pounds)  body  weight  per  twenty- 
four  hours  it  has  been  found  that  an  individual  requires  at 
rest  25  calories  and  at  light  work  30  calories.  Experiments 
have  demonstrated  that  the  heat  which  is  liberated  in  the 
body  from  the  combustion  of  1  gram  of  protein  or  of  carbo- 
hydrate produces  4  calories,  from  1  gram  of  fat  9  calories,  and 
from  1  gram  of  alcohol  7  calories.  Fat  is,  as  we  would  expect, 
more  than  twice  as  nourishing  as  carbohydrate  or  protein. 
With  these  figures  in  mind,  it  is  easy  to  estimate  with  suffi- 
cient exactness  from  dietetic  tables  the  calories  in  the  diet, 
and  to  compare  the  result  with  the  number  of  calories  required. 
For  scientific  accuracy  frequent  analyses  must  be  made  of 
samples  of  the  food  eaten. 

It  will  be  noted  in  the  above  paragraph  that  the  metric 
system  of  weights  and  measures  is  given  preference.  This 
is  done  because  it  is  far  easier  in  diabetic  work  to  deal  with 
grams  and  cubic  centimeters  than  with  ounces,  pounds  and 
quarts.  The  only  figures  in  the  metric  system  necessary  to 
remember  are  those  shown  in  Table  13. 

Table  13. — Weights  and  Measures  Employed  in  the  Estimation 
of  the  Diet. 
30  grams  =    1  ounce.1 

30  cubic  centimeters  =    1  fluidounce.2 

1 000  grams  =    1  kilogram  —  kilo  or  kg. 

(2.2  pounds). 
1000  cubic  centimeters  =    1  liter. 

16  ounces  =    1  pound  (454  grams). 

32  ounces  =    1  quart  (946  c.c). 

1  gram  carbohydrate    =  4  calories. 
1  gram  protein  =   4  calories. 

1  gram  fat  =   9  calories. 

In  estimating  carbohydrate,  protein  and  fat  in  the  diet  or 
sugar  in  the  urine,  enough  accuracy  is  obtained  in  clinical 
work  by  considering  that  30  grams  (g.)  or  30  cubic  centi- 
meters (c.c.)  equal  an  ounce,  dry  or  fluid  measure. 

1  Actually  28.4  g.  2  Actually  29.6  c.c. 


DIET  OF  NORMAL  INDIVIDUALS  57 

Individuals  with  sedentary  occupations  require  approxi- 
mately 30  calories  per  kilogram  body  weight.  Thus  a  man 
weighing  70  kilograms  (70  kilograms  X  2.2  pounds  =  154 
pounds)  would  need  (70  X  30)  2100  calories.  The  caloric 
needs  of  the  body,  however,  vary  not  only  from  day  to  day 
but  from  moment  to  moment.  Thus  an  individual  lying 
down  requires  not  far  from  25  calories  per  kilogram  body 
weight,  but  at  moderate  work  30  or  more.  So  much  of  the 
twenty-four  hours  is  spent  sleeping  that  the  individual  saves 
then  what  he  uses  at  other  periods.  To  walk  one  hour  on  a 
level  road  at  the  rate  of  2.7  miles  an  hour  requires  100 
calories  above  that  of  keeping  quiet,  according  to  Lusk. 
For  a  man  to  ascend  a  flight  of  stairs  ten  feet  high  about  3 
calories  are  necessary.  Table  14  shows  the  calories  needed 
according  to  the  amount  of  work  done. 

Table   14.  —  Calories  Required  during  Twenty-four  Hours  by 
an  Adult  Weighing  Seventy  Kilograms  (One  Hundred 
and  Fifty-four  Pounds). 


Condition. 

Calories  per 

kilogram,  body 

weight. 

Calories  per 

pound,  body 

weight. 

Total  calories. 

At  rest 

At  light  work 

At  moderate  work 

At  hard  work 

.      25  to  30 
.      35  to  40 
.      40  to  45 
.      45  to  GO 

11  to  14 
16  to  18 
18  to  20 
20  to  27 

1750  to  2100 
2450  to  2800 
2800  to  3150 
3150  to  4200 

Children  require  far  more  food  than  adults  because  of 
growth  and  increased  activity.    This  is  shown  in  Table  15. 

Table  15. — -Caloric  Needs  of  Children  during  Twenty-four 

Hours.  ~ 


Age  in  years. 

kg. 

Weight 

pounds. 

Calories  per    Calories  per 

kilogram,            pound, 
body  weight,  body  weight. 

Total 

calories. 

2 

12 

26 

80                     36 

960 

6 

20 

44 

70                     31 

1400 

12 

36 

80 

50                     23 

1800 

Composition  of  the  Normal  Diet. — The  ordinary  diet  for  a 
man  at  moderate  physical  work  would  contain  about  400 
grams  of  carbohydrate,  100  grams  of  protein  and  100  grams 
of  fat.  This  would  amount  to  2900  calories  in  the  twenty- 
four  hours,  or  about  40  calories  per  kilo  for  an  individual 


Calories, 

Total 

per  gram. 

calories. 

4 

1600 

4 

400 

9 

900 

58  DETAILS  OF  DIABETIC  TREATMENT 

weighing  70  kilograms.  These  figures  would  be  proportion- 
ately reduced  both  for  those  of  lower  body  weight  and  for 
those  with  lighter  occupations  who  would  require  nearer 
30  calories  per  kilo.  As  age  advances  the  metabolic  require- 
ments are  lessened ;  thus  if  2000  calories  are  required  at  thirty 
years,  1800  calories  will  suffice  at  seventy  and  1600  at  eighty 
years  of  age. 

Table  16. — The  Proportion  of  Carbohydrate,  Protein  and 
Fat  in  the  Normal  Diet. 

Quantity, 
Food.  grams. 

Carbohydrate      ....     400 

Protein 100 

Fat 100 

2900 

Chittenden,  in  his  painstaking  and  scientific  manner, 
accomplished  an  immense  amount  of  good  when  he  showed 
that  people  ordinarily  consumed  much  more  food  than 
physiological  needs  demand.  He  suggests  that  it  is  more 
than  probable  that  this  excess  of  food  is  in  the  long  run 
detrimental  to  health,  weakening  rather  than  strengthening 
the  body  and  defeating  the  very  object  of  nutrition. 

From  the  preceding  statements  it  will  be  seen  that  55  per 
cent,  of  the  -energy  of  the  diet  of  the  normal  individual  con- 
sists of  carbohydrate.  These  figures  are  only  approximate, 
but  they  leave  no  doubt  as  to  how  large  a  place  sugar  and 
starch  occupy  in  the  daily  ration.  Fig.  8  shows  graphically 
the  relative  caloric  value  of  the  different  foodstuffs  in  the 
total  diet. 

The  quantity  of  protein  in  the  normal  diet  is  probably 
decidedly  less,  than  100  grams.  From  Cannon's  investi- 
gations at  the  Harvard  Medical  School  it  would  appear 
that  these  active,  hard-working  students,  with  their  regular 
activities,  ate  about  90  grams  each  day.  There  is  compara- 
tively little  doubt  but  that  it  is  safe  for  an  individual  to  get 
along  on  1  gram  protein  for  each  kilogram  body  weight,  and 
I  have  no  worries  if  my  patients  secure  60  grams  protein, 


DIET  OF  NORMAL  INDIVIDUALS 


59 


though  the  students  ate  rather  more.  Protein  is  animal 
food  to  a  large  degree ;  hence  its  cost.  This  is  an  added  reason 
for  being  sparing  in  the  use  of  protein.  There  is  also  still 
another  reason,  for  when  an  excess  of  protein  is  burned  the 
other  foods  are  also  consumed  more  rapidly,  and  there  is 
more  chance  for  the  heat  produced  to  go  to  waste. 

The  quantity  of  fat  in  the  normal  diet  varies,  partly  from 
choice  and  partly  from  economic  reasons.  In  general,  in 
those  cases  in  which  the  carbohydrate  in  the  diet  is  high,  the 
fat  is  low,  and  vice  versa.  The  Voit  standard  placed  the  fat 
at  55  grams,  but  in  a  series  of  1300  dietary  studies  of  families, 
carried  out  among  different  races  and  in  different  countries, 
it  was  shown  that  the  average  quantity  of  fat  eaten  was 
about  135  grams  (4.5  ounces)  per  person  per  day,  the  varia- 
tion recorded  being  from  45  to  390  grams  per  person  per  day. 


400  G.   CAflB. 
1600  C.MS. 


100  Q.    FAT 
900  CALS. 


Fig.  8. — The  relative  caloric  value  of  protein,  carbohydrate  and  fat  in  a 

normal  diet. 


The  more  agreeable  varieties  of  fat,  such  as  butter,  cream 
and  oil,  are  expensive  foods.  Fat-js  also  a  concentrated  food, 
not  only  because  it  has  twice  the  caloric  value  of  either 
carbohydrate  or  protein,  but  because  it  occurs  more  fre- 
quently in  pure  form.  Oil,  butter  and  lard  contain  little 
water,  whereas  except  for  pure  sugar  and  stanch  most  carbo- 
hydrates and  proteins  are  diluted  five  to  ten  times  with 
water. 

The  chief  source  of  error  in  calculating  "the  total  caloric 
value  of  the  diet,  and  especially  of  the  diabetic  diet,  is  in  the 
estimation  of  fat.  Anyone  can  realize  this  upon  examining 
a  piece  of  meat  with  its  fringe  of  fat.    The  fat  in  bacon  is 


60  DETAILS  OF  DIABETIC  TREATMENT 

most  variable,  and  in  amount  its  value  can  only  be  approxi- 
mately estimated.  Portions  of  bacon  lose  varying  quantities 
of  weight  in  the  cooking,  as  shown  in  Table  17.  (See  the 
column  for  percentage  loss.) 


Table  17.- 

-Loss 

OP 

Weight  op 

Bacon 

DURING 

COOKI 

Uncooked, 

Cooked, 

Lost, 

grams. 

grams. 

per  cent. 

80 

4G 

43 

200 

100 

50 

50 

17 

66 

60 

23 

62 

30 

10 

67 

Eggs  in  some  cities  by  law  must  weigh  a  pound  and  a  half 
a  dozen,  an  average  of  GO  grams  (2  ounces)  apiece.  Such  eggs 
contain  approximately  6  grams  of  protein  and  6  grams  of 
fat.  How  gross  our  caloric  reckonings  are  is  obvious  if  a 
collection  of  eggs  is  weighed  and  the  minimum  and  maximum 
weights  noted.  The  weight  of  the  heaviest  egg  in  such  a 
collection  was  72  per  cent,  more  than  that  of  the  lightest. 
(See  Table  18.) 

Table  18. — Variations  in  Weights  of  Eggs  with  the  Shells. 


Number  of  eggs 

Minimum, 

Maximum, 

Variation, 

weighed. 

grams. 

grams. 

per  cent. 

9 

52 

63 

21 

12 

40 

62 

55 

11 

56 

63 

12 

12 

51 

69 

35 

12 

48 

66 

38 

The  weight  of  one  egg  shell  is  usually  about  7  grams. 

Milk  may  be  employed  in  the  treatment  of  diabetes,  but 
it  must  be  prescribed  and  taken  with  care,  because  of  the 
large  quantity  of  carbohydrate,  protein  and  fat  which  it 
contains.  A  glass  of  milk  is  drunk  so  easily  that  one  is  apt 
to  forget  that  it  contains  12  grams  carbohydrate,  8  grams 
protein  and  8  grams  fat.  The  graphic  table  given  below 
(Fig.  9)  will  make  this  clear.  Skimmed  milk  and  buttermilk 
contain  the  same  quantity  of  carbohydrate  and  protein  as 
whole  milk,  but  differ  from  it  in  the  absence  of  fat.    Thirty 


DIET  OF  NORMAL  INDIVIDUALS 


61 


c.c.  (one  ounce)  of  skimmed  milk,  whole  milk  or  buttermilk 
contain  1.5  grams  of  carbohydrate  and  1  gram  of  protein,  and 
1  quart  of  milk  contains  approximately  48  grams  carbo- 
hydrate and  32  grams  protein.  Skimmed  milk  and  buttermilk 
therefore  are  carbohydrate-protein  food.  Whey  contains 
carbohydrate,  but  practically  no  protein  or  fat. 

Diabetic  patients  seldom  become  sugar-free  on  a  milk 
diet.  They  may  become  sugar-free  if  so  little  milk  is  taken 
that  the  patient  is  partially  fasting. 


QUANTITY 
(30  GRAMS 
OR    1  OUNCE) 

|::i;]=CARB.                  HH||]=PROTEIN                                     ^  =  FAT 

5                     10                    15                    20                   25                   30 

CALORIES 

SKIMMED  MILK 
MILK 

CREAM  205( 
CREAM  40% 
BUTTERMILK 
BUTTER 
WHEY 
CHEESE 

ir 

10 

20 

r 

1 

60 

m 

p**= 

10 

i 

w 

r 

225 

T 

i 

N 

i 

-j- 

130 

Fig.    9. — Milk    and    milk    products.       Carbohydrate,    protein    and    fat   in 
30  grams  or  1  ounce.    Each  lineal  division  represents  1  gram. 


The  high  nutritive  value  of  cream,  butter  and  cheese  is 
evident  from  Fig.  9.  This  makes  these  special  milk  products 
desirable,  but  if  carelessly  taken*  danger  of  acid  poisoning 
arises  from  the  large  amount  of  fat  which  they  contain.  The 
high  protein  value  of  milk — 1  gram  to  the  ounce,  32  grams 
to  the  quart — is  important  to  consider,  not  alone  because 
of  the  protein  itself,  but  also  because  from  protein  sugar  is 
often  formed.  Cheese  contains  about  half  again  as  much 
protein  as  fish. 

Caloric  Values  which  Every  Doctor  Should  Know  by  Heart. — 
The  quantity  of  carbohydrate,  protein  and  fat  in  the  diet 
must  be  known  by  physician  and  patient  if  a  case  of  diabetes 
is  to  be  treated  in  modern  fashion.    The  value  of  the  different 


62  DETAILS  OF  DIABETIC  TREATMENT 

foods  in  the  diet  can  easily  be  calculated  from  Table  10. 
This  is  a  sufficiently  accurate  arrangement,  because  except 
in  the  most  exact  experiments  the  errors  in  the  preparation 
of  the  food  are  too  great  to  warrant  closer  reckoning. 

Repeatedly  physicians  and  patients  have  requested  me 
to  arrange  the  common  articles  of  the  diabetic  diet  men- 
tioned in  Table  10  in  terms  of  household  measure.  To  a 
considerable  extent  this  is  impracticable,  because  the  diabetic- 
diet  deals  with  so  small  a  quantity  of  carbohydrate.  For 
this  reason  the  only  safe  way  for  diabetic  patients  at  the 
commencement  of  their  training  is  to  weigh  their  food. 
After  a  few  days  of  weighing,  patients  can  select  utensils 
which  conform  to  the  size  of  the  portions  of  their  own  special 
diets  and  use  these  exclusively.  Two  such  utensils  are  shown 
in  Fig.  10. 


a  b 

Fig.  10. — a,  a  ramekin  this  size  holds  45  c.c.  of  water,  or  3  tablespoonfuls; 
b,  a  pitcher  graduated  to  15  c.c.;  capacity,  60  c.c. 

The  ramekin  level  full  of  Quaker  Oats  holds  30  grams. 
When  packed  tightly  with  5  per  cent,  vegetables  or  potato 
it  holds  90  grams,  but  when  filled  loosely  in  the  ordinary 
manner,  75  grams.  The  pitcher  holds  00  c.c,  or  2  ounces, 
and  is  graduated  to  15  c.c.  (Ramekin  and  pitcher  were 
arranged  for  me  by  Jones,  McDuffee  &  Stratton  Company, 
of  Boston,  Mass.) 


DIET  OF  NORMAL  INDIVIDUALS  63 

Patients  and  physicians  often  err  in  thinking  their  com- 
putations of  the  diet  are  extremely  accurate.  In  order  to 
demonstrate  the  errors  which  easily  arise  from  general 
statements  about  foods.  Fig.  11  is  inserted. 


Fig.  11. — Variations  in  the  sizes  of  common  foods. 


64  DETAILS  OF  DIABETIC  TREATMENT 

Fig.  11  shows: 

1.  How  readily  errors  may  occur  in  estimating  the  food 
values  of  the  diet  unless  definite  quantities  of  foodstuffs  arc 
prescribed. 

2.  The  absurdity  of  reckoning  food  values  to  the  fraction 
of  a  gram  unless  actual  analyses  of  each  food  as  served  are 
made. 

Errors  in  eggs  may  compensate  themselves,  because  the 
eggs  average  about  60  grams  (and  must  so  average  in  some 
communities);  errors  in  potatoes,  oranges  and  grape  fruit 
must  necessarily  be  very  great.  The  largest  of  the  three 
potatoes  is  actually  a  small  potato;  the  potato  weighing 
60  grams  is  about  the  size  of  an  egg;  the  oranges  from  left 
to  right  are  sold  under  the  trade  names  of  120,  170  and  250 
(to  the  box)  and  the  grape  fruit  under  the  trade  names  of  28, 
64  and  96  (to  the  box). 


Three  Eggs. 

Grams. 

Grams. 

Grams. 

Weight  of  one  egg 
Protein  in  one  egg 
Fat  in  one  egg  . 

....        70 
.      .      .      .          7 
.      .      .      .         7 

00 
6 
6 

50 
5 
5 

Three  Potatoes. 

Weight  of  one  potato       ....      120 
Carbohydrate  in  potato     ...       24 

90 
18 

60 
12 

Three  Oranges. 

Weight  of  one  orange 
Carbohydrate  in  one 

.      .      .      .      350 
orange  .      .        20 

Three  Grape  Fruit. 

225 
15 

150 
10 

Weight  of  one  grape  fruit      .      .      .      900 
Carbohydrate  in  one  grape  fruit  .        40 

600 
30 

300 
20 

It  is  partly  on  account  of  the  ease  with  which  large  errors 
in  the  carbohydrate  content  of  food  may  occur  that  it  is 
desirable  to  give  to  patients  with  a  low  carbohydrate  toler- 
ance their  carbohydrate  in  the  form  of  5  per  cent,  vegetables 
exclusively,  for  an  error  in  weighing,  reaching  120  grams 
(4  ounces),  would  amount  to  but  a  few  grams  of  carbohydrate. 

The  weights  and  food  values  given  for  the  various  foods  in 
the  illustration  are  not  absolutely  but  they  are  approximately 
correct. 


CHAPTER   II. 

THE  DIET  OF  DIABETIC  INDIVIDUALS. 

The  Normal  and  Diabetic  Diets  Compared.— Four-sevenths 
of  the  calories  of  the  diet  in  health  are  made  up  of  carbo- 
hydrate, two-sevenths  of  fat  and  one-seventh  protein;  but 
in  diabetes  the  diet  is  composed  almost  exclusively  of  the 
latter  two  foods.  This  is  not  discouraging,  for  until  recently 
the  Eskimo's  diet  contained  only  about  one-seventh  carbo- 
hydrate. It  takes  time  and  experience  to  learn  to  live  suc- 
cessfully upon  a  diabetic  diet,  and  it  is  only  with  time  that 
the  body  adjusts  itself  to  a  diet  with  so  marked  a  reduction 
of  carbohydrate  and  so  marked  an  increase  in  fat.  It  is 
indeed  wonderful  that  it  is  possible  for  the  body  to  do  so  at  all. 


CARBOHYDRATE 
PROTEIN 

NORMAL 

DIABETIC 

i^^^^ 

|250 

.. 

:      ]5oci. 

:     ,  [ 

wmm 

75 

G. 

1 

FAT 

H  6b  cj 

H       c. 

Foods  arranged  in  grams. 

Fig.   12.— The  diet  of  a  normal   and  of   a  diabetic    individual    compared. 

Weight  of  each  patient  60  kilograms  (60  X  2.2  =  132  pounds) . 


Foods  arranged  in  calories. 
Fig.  13.— Same  as  Fig.  12. 


In  Figs.  12  and  13  the  carbohydrate,  protein  and  fat  in  the 
normal  and  diabetic  diets  are  graphically  compared  by  weight 
and  by  calories.     It  is  assumed  in  this  comparison  that  a 
5, 


66  DETAILS  OF  DIABETIC  TREATMENT 

diabetic  patient  has  a  tolerance  for  50  grams  carbohydrate. 
It  will  be  noted  that  the  total  caloric  value  of  the  diabetic 
diet  is  slightly  less  than  the  normal  diet.  This  is  so  arranged 
with  design,  partly  because  the  diabetic  patient  is  usually 
less  active  and  partly  because,  by  a  slight  restriction  of  diet, 
the  opportunity  for  improvement  of  the  diabetes  is  favored. 

Caloric  Needs  of  the  Diabetic. — The  diet  of  the  diabetic 
patient  should  contain,  except  for  brief  intervals,  the  mini- 
mum number  of  calories  which  the  normal  individual  would 
require  under  similar  conditions.  I  am  convinced  that  many 
normal  individuals  actually  live  upon  less  than  30  calories 
per  kilo,  and  repeatedly  one  sees  diabetic  patients  over  fifty 
years  of  age  who  comfortably  live  upon  less  for  long  periods. 
This  is  true  for  the  untreated  diabetic.  If  the  patient  is 
allowed  more  than  the  minimum  amount  of  food  there  is  far 
more  likelihood  that  a  portion  will  be  unassimilated  and 
appear  as  sugar  in  the  urine.  One  of  the  first  rules  for  the 
diabetic  patient  to  learn  is  never  to  overeat.  He  should 
be  a  model  in  food  conservation  for  his  household.  As  a 
matter  of  fact,  during  scientific  treatment  he  always  returns 
a  clean  plate  because  his  appetite  is  always  equal  to  the  food 
allowed. 

Carbohydrate  in  the  Diabetic  Diet. — The  total  carbohydrate 
in  the  diet  of  diabetic  patients  is  almost  invariably  restricted, 
and  seldom  exceeds  100  grams.  This  is  a  decrease  to  approxi- 
mately 25  per  cent,  of  the  normal  carbohydrate  ration,  and 
so  radically  changes  the  composition  of  the  normal  diet  as 
to  make  it  self-evident  that  rapid  changes  from  a  normal  to  a 
diabetic  diet  containing  even  100  grams  carbohydrate  might 
easily  cause  indigestion  in  normal  as  well  as  in  diabetic 
individuals.  The  decrease  in  carbohydrate  must  be  com- 
pensated by  an  increase  in  fat. 

The  Estimation  of  the  Carbohydrate  in  the  Diabetic  Diet. — 
The  quantity  of  carbohydrate  in  various  foods  is  easily 
calculated  and  far  more  simply  than  is  usually  thought. 
(See  Table  10,  p.  54,  and  Fig.  7,  p.  52,  with  accompanying 
text.) 

Carbohydrate  in  Vegetables. — It  would  appear  perplexing  to 
determine  the  amount  of  carbohydrate  in  the  various  vege- 


DIET  OF  DIABETIC  INDIVIDUALS  67 

tables  which  the  patient  eats  in  twenty-four  hours,  but  this 
is  really  not  the  case.  It  is  true  that  there  is  considerable 
variation  in  each  group  in  Table  5,  but  the  average  content 
is  not  far  from  that  represented,  the  error  being  on  the  lower 
side.  This  does  not  hold  for  string  beans,  for  often  trouble 
occurs  from  the  beans  having  developed  into  maturity,  thus 
greatly  increasing  their  content  in  carbohydrate.  Many  an 
unexplained  trace  of  sugar  in  the  urine  has  undoubtedly 
occurred  in  this  way. 

One  will  not  be  very  wrong  if  he  considers  the  total  carbo- 
hydrate of  the  5  per  cent,  vegetables  which  a  diabetic  patient 
will  eat  in  the  twenty-four  hours  as  10  to  20  grams.  This  is 
why  in  mild  cases  of  diabetes  it  is  unnecessary  to  weigh  the 
vegetables,  for  it  is  improbable  that  a  patient  will  eat  too 
much  of  these. 

Loss  of  Carbohydrate  in  Cooking  Vegetables. — Vegetables 
lose  carbohydrate  in  the  cooking,  and  this  loss  is  favored 
(1)  by  changing  the  water  in  which  they  are  prepared  two 
or  three  times,  and  (2)  by  preparing  the  vegetables  in  finely 
divided  form  so  that  the  water  can  have  easy  access  to  the 
whole  mass.  Von  Xoorden1  pointed  out  that  100  grams  of 
raw  spinach  contained  2.97  grams  carbohydrate,  but  cooked 
spinach  only  0.85  gram.  Similarly,  100  grams  of  ripe  peaches 
contained  9.5  grams  carbohydrate,  but  when  boiled  and  the 
water  changed,  only  1.8  grams.  Allen2  has  utilized  this 
method  of  removing  carbohydrate  from  vegetables  and  thus 
allows  patients  to  have  bulk  in  their  diet.  He  terms  vege- 
tables so  prepared  "thrice-cooked  vegetables,"  though  at 
the  present  moment  it  seems  more  appropriate  to  term  them 
"camouflage  vegetables."  "Under  these  conditions  the 
vegetables  may  be  boiled  through  three  waters,  throwing 
away  all  the  water.  Nearly  all  starch  is  thus  removed. 
The  most  severe  cases  generally  take  these  thrice-cooked 
vegetables  gladly  and  without  glycosuria."  Patients  often 
say  that  it  makes  little  difference  to  them  whether  the  vege- 
tables are  thrice  washed  or  not.    It  is  easy  and  useful  to  add 


1  Von  Noorden:  Die  Zuckerkrankheit,  Berlin,  1912,  p.  306. 

2  Allen:  Boston  Med.  and  Surg.  Jour.,  1915,  clxxii,  p.  241. 


68 


DETAILS  OF  DIABETIC  TREATMENT 


a  little  salt,  and  if  desired  the  vegetables  can  be  flavored 
with  meat  juices  or  meat  extracts. 

Even  when  vegetables  are  cooked  in  the  ordinary  way, 
considerable  carbohydrate,  protein  and,  what  is  quite  unfor- 
tunate, salts,  are  lost.  Few  analyses  of  cooked  vegetables 
are  available,  but  some  of  those  which  I  have  found  are 
recorded  in  the  following  table: 


Table  19. — The  Influence   of   Cooking   upon   the   Content   of 
Carbohydrate  in  Vegetables. 


Food. 
Asparagus    . 
Spinach 
Beans  (string) 
Beets 
Carrots  . 
Cabbage 
Greens  (beet) 
Onions    . 
Beets  (boiled) 
Parsnips 
Peas 
Potatoes 
Potato  chips 
Sweet  potatoes 


Carbohydrate: 
Fresh, 

per  cent. 

3.3 
3.2 
7.4 

9.7 
9.2 
5.6 

9.9 


16.9 

18.4 

27.4 


Cooked, 
per  cent. 

2.2 

2.6 

1.6 

7.4 

6.8 

3.7 

3.2 

4 . 9 

10.0 

13.2 

14.6 

20.9 

46.7 

42.1 


Through  the  kindness  of  Professor  Ruth  A.  Wardall,  of 
the  Department  of  Home  Economics  of  the  State  University 
of  Iowa,  working  in  Professor  Mendel's  laboratory  in  Yale 
University,  I  am  able  to  insert  Table  20,  which  shows  the 
carbohydrate  in  washed  vegetables. 

The  results  shown  in  this  table  are  simply  preliminary 
experiments,  but  they  are  of  so  much  value  that  they  deserve 
attention.  Professor  Wardall  finds  it  no  disadvantage  to 
use  the  boiling  temperature  for  each  of  the  extractions.  In 
the  data  recorded  below  the  extractions  were  made  by  start- 
ing the  vegetables  in  cold  water  and  then  bringing  this  to 
the  boiling-point  and  maintaining  it  at  this  temperature 
for  one  minute.  Hot  water  was  added  for  each  of  the  other 
extractions,  and  all  were  boiled  one  minute.  If  the  first 
extraction  is  kept  at  150°  F.,  as  has  sometimes  been  recom- 


DIET  OF  DIABETIC  INDIVIDUALS 


69 


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70  DETAILS  OF  DIABETIC  TREATMENT 

mended,  the  second  extraction  leads  the  list  in  removing 
carbohydrate,  the  first  extraction  ranking  after  the  third  or 
fourth.  In  general,  100  grams  of  the  fresh,  clean,  dry  vege- 
table, weighed  from  the  edible  portion,  were  used  for  each 
analysis,  and  all  calculations  were  made  on  this  basis.  With 
the  exception  of  canned  asparagus  the  four  or  five  extractions 
necessary  to  remove  all  reducing  substances  left  the  vege- 
tables still  attractive  in  flavor  and  appearance.  Professor 
Wardall  has  further  reported1  that  repeated  washings  with 
water  will  remove  the  carbohydrate  from  beets  and  parsnips; 
3  in  the  case  of  the  beets  and  7  in  the  case  of  the  parsnips. 

For  practical  purposes  three  extractions  will  probably  be 
found  sufficient.  For  the  first,  place  the  vegetables  in  cold 
water  and  bring  the  same  to  the  boiling-point,  maintaining 
the  temperature  for  three  to  five  minutes,  but  for  the  others 
begin  with  hot  water. 

The  Carbohydrate  in  Various  Foods. —  1.  Potatoes. — The 
variation  in  the  percentage  of  carbohydrate  in  potatoes 
before  and  after  cooking  is  negligible,  save  with  potato 
chips,  in  which  it  more  than  doubles.  The  loss  of  protein 
is  slight,  but  if  soaked  in  cold  water  before  boiling  the  loss 
of  protein  is  25  per  cent,  and  of  mineral  matter  38  per  cent. 
If  the  potatoes  are  not  soaked  but  dropped  at  once  into 
boiling  water  the  loss  is  much  decreased,  and  if  the  potatoes 
are  boiled  with  the  skins  on  the  loss  is  very  slight.  Emphasis 
should  be  laid  upon  the  comparatively  small  amount  of 
carbohydrate  in  potato  in  comparison  with  its  bulk  and  in 
comparison  with  the  percentage  of  carbohydrate  in  bread. 
A  considerable  number  of  my  milder  cases  of  diabetes,  by 
giving  up  bread  and  bread  preparations  entirely,  have  been 
able  to  eat  potatoes  freely.  In  prescribing  potatoes  for 
diabetic  patients  it  is  desirable  to  designate  baked  potatoes, 
for  these  can  be  eaten  with  the  skins  if  pains  are  taken  to 
have  them  carefully  cleaned  with  a  scrubbing  brush  in  the 
kitchen.  This  is  advantageous  in  two  ways:  the  skins  are 
quite  an  addition  to  the  meager  diet  of  the  diabetic,  and 
furthermore,  they  counteract  constipation. 

1  Am.  Med.  Assn.,  1917,  lxix,  p.  1859. 


DIET  OF  DIABETIC  INDIVIDUALS  71 

2.  Nuts. — Xuts  containing  15  and  20  per  cent,  carbo- 
hydrate are  probably  far  less  objectionable  than  most  other 
foods  with  a  similar  carbohydrate  content.  This  is  due  to 
the  fact  that  in  such  nuts  as  almonds  and  peanuts  a  larger 
part  of  the  carbohydrate  is  in  the  form  of  pentosan,  galactan 
or  other  hemicelluloses  which  probably  do  not  readily  form 
sugar. 

3.  Fruit. — Fruit  is  most  desirable  for  a  diabetic  patient 
if  his  tolerance  will  allow  him  to  take  it.  The  taste  is  agree- 
able, it  serves  instead  of  a  dessert,  and  so  relieves  the  patient 
of  the  embarrassment  of  sitting  idly  at  the  table  when  others 
are  eating.  The  best  varieties  of  fruit  for  diabetic  patients 
are  grape  fruit  (5  per  cent.),  strawberries  (7  per  cent.)  and 
oranges  (11  per  cent.).  These  fruits  are  safer  for  the 
patient  than  apples  (15  per  cent.),  because  they  contain 
5  to  10  per  cent,  less  carbohydrate  and  are  more  satisfying. 
Furthermore,  it  is  less  easy  thoughtlessly  to  eat  an  orange 
than  an  apple  and  thus  break  dietetic  restrictions. 

4.  Oranges. — The  quantity  of  carbohydrate  in  a  small 
orange  is  about  10  grams.  The  same  statement  will  apply 
to  one-half  a  small-sized  grape  fruit.  One  will  not  be  far 
wrong  to  consider  that  one  compartment  of  a  small  orange 
contains  1  gram  carbohydrate.  The  illustration  on  p.  63 
shows  that  larger  oranges  and  larger  grape  fruit  easily  con- 
tain twice  as  much  carbohydrate  as  do  the  smaller  varieties. 

5.  Bananas. — Bananas  can  seldom  be  taken  by  diabetic 
patients  because  the  content  of  carbohydrate  is  so  high, 
being  equivalent  to  that  in  potato.  In  general,  the  riper  a 
banana,  and  for  that  matter  any  vegetable  or  fruit,  the 
more  the  starch  in  it  has  changed  to  sugar,  and  also  the  more 
carbohydrate  it  contains.  Since  unripened  fruits  with  their 
lower  carbohydrate  content  can  be  made  palatable  by 
cooking,  a  way  is  afforded  for  diabetic  patients  to  use  them. 

6.  Ripe  Olives. — Ripe  olives  make  a  pleasing  change  in 
the  diet.  They  contain  4  per  cent,  carbohydrate  in  contrast 
to  green  olives,  which  contain  1.8  per  cent.  Furthermore, 
ripe  olives  are  more  easily  digested.  Five  ripe  or  ten  green 
olives  contain  1  gram  carbohydrate  and  5  grams  of  fat. 
The  quantity  of  protein  in  ten  olives  is  about  1  gram. 


72  DETAILS  OF  DIABETIC  TREATMENT 

7.  Milk.— The  carbohydrate  in  milk  is  in  the  form  of 
lactose  and  can  be  reckoned  at  5  per  cent.,  or  1.5  grams 
per  30  c.c.  or  1  ounce.  It  is  the  same  in  skimmed  milk, 
buttermilk  and  whey;  but  cream  and  koumiss  contain  about 
3  per  cent.,  or  1  gram  carbohydrate  to  the  ounce.  Butter- 
milk contains  essentially  the  same  quantity  of  carbohydrate 
and  protein  as  milk,  but  only  a  trifling  amount  of  fat.  I  cannot 
understand  why  doctors  so  frequently  give  it  to  their  patients. 

8.  Oatmeal. — Oatmeal  is  two-thirds  carbohydrate.  In 
calculations  one  should  always  be  guided  by  the  dry  weight, 
because  the  different  preparations  vary  greatly  in  bulk  and 
weight  when  cooked.  It  is  a  simple  matter  for  a  few  days 
to  weigh  out  30  grams  (1  ounce)  of  dry  oatmeal  containing 
20  grams  carbohydrate,  have  it  cooked  and  note  the  bulk. 
By  dividing  the  oatmeal  thus  cooked  into  four  portions  each 
would  contain  5  grams  carbohydrate. 

In  weighing  foods  one  should  never  attempt  to  weigh  out 
quantities  as  small  as  5  grams  with  the  usual  variety  of  scales. 
A  more  reliable  result  is  obtained  by  weighing  out  multiples 
of  5  grams  and  then  dividing  into  enough  portions  to  make 
each  portion  5  grams. 

9.  Bread. — The  carbohydrate  in  white  wheat  bread 
amounts  to  about  53  per  cent.  If  the  bread  is  toasted, 
enough  water  is  lost  to  raise  the  percentage  of  carbohydrate 
in  the  toast  to  about  60  per  cent.  If  the  bread  is  made 
without  sugar  and  with  water  instead  of  milk  the  carbo- 
hydrate content  is  lowered  and  may  amount  to  only  45 
per  cent.  Coarse  breads  if  made  without  sweetening  or 
milk  would  contain  slightly  less  carbohydrate.  It  is  undesir- 
able to  give  bread  to  diabetic  patients  unless  their  tolerance 
is  very  high,  because  they  can  take  so  little  without  causing 
glycosuria  that  the  bread  is  simply  an  aggravation.  An 
error  in  weight  of  1  ounce  of  a  5  per  cent,  vegetable  amounts 
to  1  gram  carbohydrate,  of  potato  to  6  grams,  but  of  bread 
to  18  grams.  Crackers  and  zweiback  contain  still  less 
water  than  toast,  and  in  consequence  the  percentage  of  car- 
bohydrate is  raised  to  the  neighborhood  of  70  per  cent. 
Many  gluten  breads  upon  the  market  contain  as  much  as 
30  per  cent,  carbohydrate. 


DIET  OF  DIABETIC  INDIVIDUALS  <3 

Protein  in  the  Diabetic  Diet. — The  quantity  of  protein 
required  by  diabetic  patients  varies  with  the  age,  weight 
and  activity  of  the  case  as  well  as  with  the  condition  of  the 
kidneys.  It  is  a  safe  rule  at  the  beginning  of  treatment  to 
attempt  to  increase  the  protein  gradually  up  to  the  same 
quantity  as  that  required  by  a  normal  individual. 

Chittenden  points  out  that  60  grams  (one-half  the  old 
standard  protein)  are  quite  sufficient  to  meet  all  the  real 
physiological  needs  of  the  body  under  ordinary  conditions 
of  life  and  with  most  individuals  not  leading  an  active  out- 
of-door  life  even  smaller  amounts  will  suffice.  Chittenden, 
weighing  57  kilograms,  and  Mendel  weighing  70  kilograms, 
lived  respectively  on  34  and  41  grams  protein  daily,  the 
former  for  nine  and  the  latter  for  seven  months.  Until  the 
Chittenden  low-protein  diet  is  proved  to  be  entirely  satis- 
factory for  healthy  individuals  over  a  long  period  of  years 
it  is  best  not  to  have  recourse  to  it  for  long  periods  in  the 
treatment  of  diabetes.  Temporarily  small  quantities  may 
be  given,  but  safety  lies  not  far  from  1  gram  protein  to  each 
kilogram  body  weight. 

It  has  been  claimed  that  vegetable  proteins  give  rise  to 
less  carbohydrate  than  do  animal  proteins.  As  a  matter 
of  fact,  carbohydrate  may  be  formed  out  of  any  protein. 

Meat  and  Fish. — The  study  of  the  chemical  composition  of 
meat  and  fish  is  simplified  for  the  diabetic  patient  by  the 
fact  that  except  in  liver  and  shell-fish,  carbohydrate  is  absent. 
Even  in  liver  the  quantity  of  carbohydrate  is  almost  negli- 
gible when  we  consider  the  amount  and  frequency  with 
which  this  article  of  food  is  eaten.  The  analyses  of  liver 
and  shell-fish  will  be  found  in  the  tables  on  pages  150  and  151. 

The  chief  difficulty  in  computations  of  the  nutritive  value 
of  meat  and  fish  is  due  to  the  varying  content  of  fat.  Thus, 
the  edible  portion  of  chicken  may  contain  on  the  average 
only  2.5  per  cent,  of  fat,  whereas  lean  ham  may  contain  14 
per  cent,  of  fat,  fat  ham  as  much  as  50  per  cent.,  and  smoked 
bacon  65  per  cent.,  though  lean  smoked  bacon  42  per  cent. 
In  general,  a  mixture  of  cooked  lean  meats  probably  contains 
not  far  from  10  to  15  per  cent,  of  fat. 

Fish  differs  from  meat  chiefly  in  the  small  quantity  of  fat. 


74  DETAILS  OF  DIABETIC  TREATMENT 

Even  salmon,  which  contains  more  fat  than  most  other  fish, 
showed  in  its  analysis  only  12.8  per  cent,  fat,  shad  9.5  per 
cent,  and  herring  and  mackerel  7.1  per  cent.  In  general, 
other  kinds  of  fish  show  6  per  cent,  or  less  of  fat.  Halibut 
steak,  for  example,  contains  5.2  per  cent,  and  cod  0.4  per 
cent.  Preserved  fish,  however,  is  quite  rich  in  fat;  thus 
sardines  contain  19.7  per  cent.  In  substituting  fish  for  meat, 
my  patients  are  taught  to  add  from  \  to  1  teaspoonful  of 
olive  oil  to  the  diet  for  each  30  grams  of  fish. 

The  quantity  of  protein  in  meat  also  varies  considerably 
and  usually  falls  as  the  percentage  of  fat  rises.  A  value  of 
20  per  cent,  for  protein  in  uncooked  lean  meat  represents 
about  the  average  and  this  is  increased  to  25  per  cent,  or 
more  when  the  meat  is  cooked.  The  quantity  of  protein  in 
fish  is  very  slightly  less  than  that  in  meat.  Fish  is  especially 
desirable  in  the  early  days  of  protein  feeding  following  the 
preliminary  carbohydrate-feeding  days,  because  in  fish  the 
quantity  of  fat  is  so  low.  Shell-fish  make  agreeable  additions 
to  the  diet:  (1)  they  are  desirable  because  they  are  pala- 
table; (2)  they  are  bulky  foods  and  so  are  satisfying;  (3) 
they  furnish  a  separate  course  at  a  meal.  Half  a  dozen 
oysters  or  clams  are  quite  sufficient.  The  edible  portion 
of  a  medium-sized  oyster  on  the  shell  weighs  on  the  average 
half  an  ounce,  and  half  a  dozen  oysters  would  amount  to 
90  to  100  grams.  The  six  would  contain  about  4  grams 
carbohydrate,  6  grams  protein  and  1  gram  fat,  the  equivalent 
of  50  calories.  Half  a  dozen  clams  on  the  shell  (edible  por- 
tion) weigh  35  grams  and  contain  0.7  gram  carbohydrate, 
3  grams  protein,  and  a  negligible  quantity  of  fat. 

Broths. — Broths  are  so  extensively  used  on  fasting  days 
and  for  lunches  for  diabetic  patients  that  their  composition 
deserves  notice.  As  a  rule  the  nutritive  value  of  a  broth 
made  for  diabetic  patients  should  be  negligible.  That  this 
may  be  the  case  the  broth  should  be  skimmed  free  of  fat, 
and  obviously  should  be  clear  so  as  to  be  free  from  particles 
of  meat  fiber.  The  broths  should  be  thin,  because  a  jelly- 
like broth  would  contain  a  large  quantity  of  protein  in  the 
form  of  gelatin,  and  I  have  known  such  broths  to  prevent 
diabetic  patients  from  rapidly  becoming  sugar-free  when 


DIET  OF  DIABETIC  INDIVIDUALS  75 

they  were  allowed  broths  freely  on  otherwise  fasting  days. 
Canned  meat  extracts  contain  very  little  nourishment. 
The  danger  in  broths  lies  in  the  amount  of  salt  which  they 
contain.  Frequently  this  is  very  great,  whereas  the  amount 
of  salt  should  be  moderate.  Patients  often  desire  to  drink 
several  cups  of  broth  a  day,  and  if  the  broth  is  heavily  salted 
all  the  salt  is  not  excreted,  but  remains  in  the  body  and 
retains  with  it  so  much  liquid  that  weight  is  increased,  and 
swelling  of  the  legs  or  even  of  the  face  may  develop.  (See 
pages  79  and  108.) 

Fat  in  the  Diabetic  Diet. — Fat  forms  the  bulk  of  the  diabetic 
patients'  diet.  Even  with  the  most  modern  ideas  upon 
treatment  this  statement  holds.  Figs.  7  (p.  52),  12  and 
13  (p.  05),  and  Table  16  give  the  proportions  which  the 
different  foodstuffs  take  in  the  diet  and  show  the  extent 
to  which  diabetic  patients  must  depend  upon  fat  to  offset 
the  loss  of  carbohydrate.  Remember  that  the  diet  of  a 
healthy  individual  of  70  kg.  at  office  work  contains  approxi- 
mately 300  grams  carbohydrate,  yielding  (300  X  4)  1200 
calories,  and  if  nearly  all  this  quantity  is  unutilized  by  the 
.diabetic  patient,  it  can  be  calculated  how  many  calories  in 
the  form  of  fat  must  be  given  to  replace  it.    Theoretie.illy, 

these  133  grams  -^— ^ —  fat  should  be  taken  in  addition  to 

the  usual  100  grams  of  fat  in  the  normal  ration;  but  practi- 
cally this  is  seldom  necessary,  partly  because  the  diabetic 
patient  is  usually  less  active  than  the  ordinary  individual. 
Furthermore,  most  diabetic  patients  have  a  tolerance  for 
quite  a  considerable  quantity  of  carbohydrate.  Finally, 
these  calculations  are  made  for  a  patient  weighing  70  kilo- 
grams. In  reality  most  diabetic  patients  weigh  far  less  and 
therefore  require  less  food. 

The  Eskimos  live  largely  upon  fat.  Diabetic  patients 
should  be  very  thankful  that  there  is  a  race  of  Eskimos 
through  which  proof  is  afforded  that  it  is  perfectly  possible 
to  maintain  life  on  a  diet  in  which  carbohydrate  is  largely 
replaced  by  fat. 

How  much  fat  should  a  diabetic  patient  eat?  This  does 
not  depend  upon  the  capacity  of  the  digestion.    The  safest 


7G  DETAILS  OF  DIABETIC  TREATMENT 

answer  would  be:  as  little  as  possible  in  order  to  maintain 
body  weight.  Unquestionably  the  quantity  will  vary  from 
time  to  time,  and  it  may  increase  with  years  without 
detriment  to  the  patient.  Nevertheless  I  am  always  glad  to 
see  a  diet  which  contains  as  much  or  half  as  much  carbo- 
hydrate as  fat;  in  other  words,  a  carbohydrate-fat  ratio  of 
1  :  1  or  1  :  2,  respectively,  and  dread  to  see  one  with  a  car- 
bohydrate-fat ratio  of  1  :  5  or  above. 

Fat  is  most  agreeably  taken  as  cream,  and  cream  which 
contains  20  per  cent,  butter  fat  is  usually  easier  to  bear  than  a 
richer  cream.  It  is  seldon  advisable  to  allow  more  than  half 
a  pint  (240  c.c.)  of  cream,  although  patients  prefer  to  increase 
the  quantity  of  cream  at  the  expense  of  other  forms  of  fat 
in  the  diet.  There  is  no  other  form  of  food  from  which  a 
diabetic  patient  can  derive  more  pleasure  for  its  caloric 
value  and  yet  with  less  harm  to  himself  than  from  cream. 
Half  a  pint  of  20  per  cent,  cream  contains  48  grams  of  fat, 
and  yet  the  quantity  of  carbohydrate  or  of  protein  in  cream 
of  this  richness  is  but  little  over  8  grams,  and  may  be  esti- 
mated in  clinical  work  as  8  grams,  or  1  gram  to  the  ounce. 
Occasionally  patients  tolerate  butter  more  readily  than 
cream,  and,  as  a  rule,  fresh  unsalted  butter  is  preferred. 
Obviously,  when  cream  is  increased  in  the  diet,  the  butter 
must  be  decreased,  and  vice  versa.  Thirty  grams  of  butter 
contain  25  grams  of  fat,  and  this  is  a  welcome  addition  to  the 
diet.  Oleo,  butterine  and  nut  margarine  contain  no  sugar 
and  have  about  the  same  percentage  of  fat  as  butter  and  the 
cost  is  very  much  less.  Lard  being  nearly  100  per  cent,  fat 
can  be  used  to  advantage  more  than  it  now  is  in  the  diabetic's 
diet.  Crisco,  also  nearly  100  per  cent,  fat,  is  often  more  wel- 
come than  lard,  because  of  its  lack  of  flavor.  Oil  is  an  ideal 
diabetic  food,  because  it  is  a  pure  fat.  Oil  is  so  desirable 
for  a  diabetic  that  I  hesitate  to  have  a  patient  take  more 
than  15  grams  (1  tablespoonful),  lest  he  weary  of  the  same. 
If  oil  is  disliked  upon  vegetables  it  can  be  taken  in  small 
quantities  after  meals  as  a  medicine.  Italian  patients 
naturally  bear  olive  oil  unusually  well.  Olive  oil  forms  an 
excellent  lunch  for  diabetic  patients.  I  frequently  advise 
its  use  upon  retiring.     It  is  the  diabetic  patient's  cough 


DIET  OF  DIABETIC  INDIVIDUALS 


77 


medicine;  it  relieves  the  symptoms  of  his  hyperacid  stomach. 
Peanut,  corn  or  cotton-seed  oil  may  be  substituted  if  expense 
is  a  factor. 

The  Danger  of  Fat  to  the  Diabetic. — Fat  is  the  chief  source 
of  the  dreaded  acidosis,  though  to  this  in  lesser  degree  the 
amino-acids  of  the  protein  molecule  with  even  numbers  of 
carbon  atoms  contribute  as  well.  Fat,  therefore,  at  one  time 
may  save  the  life  of  the  diabetic,  but  at  another  period  may 
destroy  it.  The  close  dependence  of  acidosis  upon  a  fat  diet 
is  beautifullv  shown  in  Table  21. 


Table  21. 


-The  Dependence  of  Acidosis  upon  the  Fat  in  the 
Diet  (Williams  and  Dresbach.) 


U 

rine. 

Diet. 

Date. 

Diaoetio 
acid. 

Total 
•     XH:, 
(Folin), 
grams. 

Total 
sugar 
(polar), 
grams. 

Carbo- 
hydrate, 

grams. 

Protein, 
grams. 

Fat, 
grams. 

1912 

July     5 

+  +    , 

1.9 

48 

20 

100 

200 

6 

+  + 

2.1 

27 

65 

100 

200 

27 

+ 

0.6 

30 

90 

33 

74 

Aug.     8 

+  + 

2.7 

86 

190 

75 

200 

Oct.   20 

+ 

0.6 

45 

64 

75 

30 

31 

0 

0.3 

38 

45 

75 

30 

Nov.  12 

0 

0.5 

56 

56 

75 

30 

1913 

Jan.    28 

+  +  + 

2.6 

122 

35 

100 

21 11 1 

Feb.     2 

+  +  + 

3.0 

152 

66 

90 

200 

June  12 

+  +  +  + 

4.1 

IDS 

'.)() 

100 

21  i( ) 

July   27 

+  +  +  + 

4.4 

12.5 

200 

150 

180  f 

31 

+  +  +  + 

3.3 

172 

200 

150 

180  + 

There  is  no  more  potent  agency  in  the  prevention  of  acidosis 
than  the  withdrawal  of  fat  from  the  diet.  Allen  has  made 
us  all  his  debtors  by  a  series  of  experiments  upon  diabetic 
dogs  which  show  the  insidious  way  in  which  fat  is  harmful 
in  the  manner  in  which  it  has  been  customarily  employed 
in  the  treatment  of  diabetes.  "  Fat  unbalanced  by  adequate 
quantities  of  other  foods  is  a  poison." 

Alcohol. — The  use  of  alcohol  in  diabetes  would  seem  to  be 
indicated,  but,  as  a  matter  of  fact,  there  is  but  a  small  per- 


78  DETAILS  OF  DIABETIC  TREATMENT 

centage  of  my  patients  who  employ  it  at  all.  Theoretically, 
1  c.c.  of  pure  alcohol  yields  7  calories  in  its  combustion. 
Thus,  15  c.c.  (1  tablespoonful)  of  alcohol  or  its  equivalent 
— 30  c.c.  (2  tablespoonfuls)  of  whisky,  brandy,  rum,  or  gin — 
would  yield  105  calories  to  the  body.  Seldom,  however, 
do  I  prescribe  it  for  patients,  and  this  rule  holds  even  for 
patients  during  days  of  fasting,  Most  of  the  physicians 
with  whom  I  am  acquainted  treat  a  large  majority  of  their 
patients  without  alcohol  in  any  form. 

Liquids. — It  is  rarely  necessary  to  restrict  the  liquids  in 
diabetes.  The  diminution  of  the  carbohydrate  in  the  diet 
with  the  resulting  fall  in  the  excretion  of  sugar  usually  leads 
to  a  corresponding  diminution  in  the  thirst  and  quantity 
of  urine.  I  hesitate  to  restrict  liquids  in  severe  diabetes  for 
fear  too  little  liquid  will  be  available  for  the  body  with  which 
to  eliminate  the  acids  which  may  have  been  formed.  On  the 
other  hand,  patients  often  upset  the  digestion  by  drinking 
large  quantities  of  liquids  rapidly.  This  is  avoided  by  allow- 
ing only  half  a  glass  of  liquid  at  a  time,  though  the  patient 
is  instructed  to  take  that  as  frequently  as  desired.  Case 
No.  1196  continually  voided  large  quantities  of  urine,  but 
usually  I  could  find  a  cause  such  as  the  ingestion  of  20  or 
more  grams  of  salt,  bouillon  cubes  in  variable  number  or 
21  half-grain  saccharin  tablets  a  day.  Ice-water  should  be 
discouraged. 

Sodium  Chloride. — Salt  is  of  great  service  to  the  diabetic 
patient.  If  it  is  withdrawn  from  the  diet  the  weight  falls, 
due  to  the  simultaneous  excretion  of  water,  and  the  skin  and 
tissues  of  the  patient  are  obviously  dry. 

In  the  early  days  of  fasting  treatment,  patients  often  lost 
much  weight  because  water  alone  was  allowed.  For  example, 
I  learned  of  one  case  who  lost  thirteen  pounds  in  four  days  in 
this  manner.  When  broths  are  freely  given  during  fasting 
it  is  not  uncommon,  particularly  in  the  presence  of  acidosis, 
to  see  a  patient  gain  weight,  and  invariably  such  patients 
feel  better  than  those  who  lose. 

Salt  is  very  freely  used  by  diabetic  patients.  I  do  not 
remember  to  have  ever  seen  a  diabetic  patient  who  took 
too  little  salt.    One  of  my  fasting  cases  was  accustomed  to 


DIET  OF  DIABETIC  INDIVIDUALS  79 

shake  it  into  his  hand  to  eat.    Patients  will  often  salt  their 
broths,  although  they  contain  considerable  salt. 

The  fact  that  it  is  harmful  for  a  diabetic  patient  to  take 
large  quantities  of  salt  is  frequently  shown  by  the  excessive 
quatities  of  urine  which  they  are  obliged  to  void,  though 
sugar-free,  and  by  the  swelling  which  may  appear  in  legs 
and  ankles.  However,  it  should  be  stated  that  I  have  never 
known  a  patient  with  dropsy  to  develop  diabetic  coma, 
and  I  recall  but  one  instance  of  a  patient  in  diabetic  coma 
in  whom  dropsy  appeared.  The  withdrawal  of  salt  from  the 
diet  of  Case  No.  137S  wrought  surprising  changes  in  her 
weight  and  her  dropsy  entirely  disappeared.  From  98 
pounds  it  fell  to  70  pounds  in  twenty-five  days  and  this  was 
due  almost  exclusively  to  the  disappearance  of  the  dropsy. 


CHAPTER  III. 

THE  TREATMENT  OF  MODERATELY  SEVERE 
AND  SEVERE  CASES  OF  DIABETES. 

The  object  of  diabetic  treatment  is  to  enable  the  patient, 
by  rearrangement  of  his  diet  and  habits  of  life,  to  live  in  a 
maimer  similar  to  that  of  the  healthy  individual.  This 
object  is  best  attained  by  preventing  the  loss  of  sugar  in  the 
urine — in  other  words,  by  keeping  the  urine  sugar-free. 
Cases  Nos.  804,  1024,  894,  564  and  632  illustrate  successful 
treatment. 

Case  No.  804  contracted  diabetes  at  the  age  of  forty-two 
years,  and  first  consulted  me  four  years  later,  December  17, 
1914,  at  the  age  of  forty-six.  His  weight  at  that  time  was 
139.  The  quantity  of  sugar  amounted  to  5.6  per  cent.,  and 
acid  poisoning  was  present.  With  restriction  of  diet  and 
fasting  he  became  sugar-free  on  December  30,  and  the 
acid  poisoning  disappeared  on  January  7.  He  left  the  hos- 
pital sugar-free,  having  gained  one  pound  by  January  11, 
and  a  year  later  his  weight  was  150.  Difficulty  occurred  in 
keeping  sugar-free,  and  he  returned  for  hospital  treatment 
on  April  22,  1917,  showing  in  a  twelve-hour  specimen  2.5 
per  cent.  (66  grams)  of  sugar  and  severe  acid  poisoning. 
In  Table  22  it  will  be  seen  that  even  four  days  of  fasting  did 
not  suffice  to  rid  the  urine  of  sugar.  This  was  followed  by 
three  days  of  restricted  diet,  when  the  institution  of  one  fast 
day  made  the  urine  sugar-free.  On  May  18  he  left  the  hos- 
pital free  from  acid  poisoning  and  sugar,  and  weighing  134 
pounds.  His  diet  then  contained  carbohydrate  15  grams, 
protein  71  grams,  fat  122  grams,  and  alcohol  12  grams, 
making  a  total  of  1526  calories.  By  August  17  he  had  been 
able  to  increase  the  diet  to  50  grains  carbohydrate,  about 
110  grams  protein,  and  110  grams  fat,  making  1600  to  1800 


MODERATELY  SEVERE  AND  SEVERE  DIABETES     81 


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82  DETAILS  OF  DIABETIC  TREATMENT 

calories  in  a  day,  and  the  weight  had  risen  to  148  pounds. 
From  the  above  it  can  be  seen  that  the  diabetes  changed 
from  the  severe  to  the  moderate  type,  and  finally  became 
mild.1 

Case  No.  1024  consulted  me  at  the  age  of  seventy-seven 
years  with  a  history  of  diabetes  of  eight  years'  duration. 
She  was  annoyed  by  symptoms  referable  to  the  circulation, 
digestion  and  skin,  and  her  age  and  discomfort  suggested 
that  it  might  not  be  worth  while  to  attempt  any  treatment. 
Treatment,  however,  was  attempted,  and  rewarded  by  the 
urine  becoming  sugar-free  and  remaining  so  at  the  end  of 
three  weeks,  but  only  upon  a  rigid  diet  containing  1  gram 
carbohydrate,  32  grams  protein,  72  grams  fat,  and  alcohol 
12  grams.  Even  upon  this  stern  regime  the  urine  remained 
sugar-free  for  only  a  few  weeks,  when  sugar  reappeared  in 
varying  quantities.  But  no  one  even  thought  of  giving  up 
the  fight  for  health.  Under  the  careful  supervision  of  skilled 
nurses,  sugar  disappeared  again,  and  the  weight,  which  had 
fallen  from  122  pounds  to  106  pounds  in  August,  1916, 
steadily  increased  to  119  pounds  the  following  summer  and 
the  patient  remained  sugar-free  over  a  period  of  months, 
with  a  diet  containing  carbohydrate  about  40  grams,  protein 
75  grams  and  fat  about  140  grams.     The  blood-pressure, 

which  was  160,  is  now  125;  Mrs. now  looks  well  and 

is  more  active  than  any  woman  I  know  of  her  age.  This 
patient,  apparently  a  severe  case  of  diabetes,  with  distressing 
symptoms,  under  careful  treatment  has  changed  to  a  case  of 
almost  mild  type. 

Occurring  at  the  other  extreme  of  life  is  Case  No.  894,  a 
little  girl,  who  developed  diabetes  at  the  age  of  one  year  and 
five  months,  although  it  was  not  discovered  until  a  year 
later.  In  March,  1915,  the  urine  showed  5.3  per  cent,  of 
sugar,  although  when  I  first  saw  her  (July  30,  1915)  she  was 
upon  a  restricted  diet,  and  but  0.2  per  cent,  was  found. 
Under  careful  treatment  she  has  remained  sugar-free  except 
during  a  brief  period  in  midsummer  of  1917,  when  confusion 

1  I  consider  the  diabetes  to  be  severe  when  sugar  appears  in  the  urine  if 
the  diet  of  the  patient  contains  not  over  10  grams  carbohydrate,  moderate 
if  between  10  and  50  grams  carbohydrate,  and  mild  if  more  than  50  grams. 


MODERATELY  SEVERE  AND  SEVERE  DIABETES      83 

existed  as  to  the  solution  used  for  testing  the  urine,  and  the 
diet  had  been  unfortunately  increased.  With  little  trouble, 
however,  she  again  became  sugar-free.  The  weight  on  August 
3,  1915,  was  33|  pounds,  and  on  August  12,  38^  pounds. 

One  of  the  most  satisfactory  cases,  Case  No.  564,  whom  I 
have  had  under  observation  was  a  boy  of  sixteen,  who  came 
to  my  then  assistant,  Dr.  F.  Gorham  Brigham,  in  November, 
1912.  Sugar  had  appeared  in  the  urine  without  previous 
symptoms  following  a  football  game  between  two  large 
preparatory  schools.  The  patient  entered  the  New  England 
Deaconess  Hospital,  where,  under  the  methods  of  treatment 
adopted  in  1912  and  1913,  he  remained  from  December  15, 
1912,  to  January  14,  1913,  without  becoming  sugar-free,  the 
quantity  of  sugar  varying  between  3.4  per  cent.  (187  grams 
in  the  twenty-four  hours)  to  0.8  per  cent.  (43  grams  in  the 
twenty-four  hours)  at  discharge.  However,  with  the  methods 
adopted  at  that  time,  under  the  supervision  of  Dr.  R.  J. 
Thompson,  of  Fall  River,  and  a  nurse  thoroughly  versed 
in  diabetic  treatment,  the  acid  poisoning,  which  had  been 
severe  and  later  amounted  to  as  much  as  is  represented  by 
5.7  grams  ammonia  in  twenty-four  hours,  disappeared,  and 
at  his  home  he  became  sugar-free  in  April,  1913.  He  has 
now  passed  a  considerable  portion  of  his  examinations  for 
college,  and  should  enter  this  coming  year.  On  September 
23,  1910,  the  urine  was  sugar-free  and  the  blood  sugar 
amounted  to  0.13  per  cent.  His  weight  naked  was  129f 
pounds  in  contrast  to  97^  pounds  on  December  17,  1912.  On 
December  26,  1916,  the  dressed  iyeight  was  134  pounds.  On 
December  27-28,  1917,  the  urine  showed  0.3  per  cent.,  or 
6  grams  sugar.  The  blood  sugar  was  0.23  per  cent,  and  the 
blood  fat  0.704  per  cent.  It  is  interesting  to  record  this  case, 
because  persistent  treatment  faithfully  followed  by  doctor, 
nurse  and  patient's  family  has  given  remarkable  results. 

Case  No.  632,  a  young  officer,  aged  thirty-five  years,  with 
diabetes  of  one  and  a  half  years'  duration,  came  to  me  first 
in  1913.  At  the  hospital  diacetic  acid  showed  repeatedly, 
and  the  ammonia  was  1.7  grains,  but  the  tolerance  for  carbo- 
hydrate lay  between  15  and  30  grams.  Nevertheless,  he  was 
discharged  with  0.5  per  cent,  of  sugar  in  the  urine,  and  diacetic 


84  DETAILS  OF  DIABETIC  TREATMENT 

acid  was  present,  with  a  diet  of  30  grams  carbohydrate  and  a 
limited  quantity  of  protein,  though  with  an  unlimited  amount 
of  fat.  He  returned  in  February,  1916,  and  it  required  twelve 
days  to  rid  the  urine  of  sugar  and  twenty-one  days  to  rid 
it  of  acid,  but  he  left  the  hospital  April  13,  having  been 
sugar-free  the  preceding  week  with  a  tolerance  for  28  grams 
carbohydrate,  79  protein,  133  fat  and  9  alcohol.  The  blood 
sugar  was  0.21  per  cent.  While  at  the  hospital  exercise  was 
utilized  to  the  limit,  and,  as  to  be  expected  of  an  army  man 
with  a  Victoria  Cross,  obedience  was  implicit,  cooperation 
ever  present  and  system  exact.  I  have  permission  to  publish 
this  letter  received  eleven  months  after  leaving  the  hospital. 

March  8,  1917. 

"I  have  really  been  wonderfully  well,  feel  splendid  and 
everyone  remarks  how  well  I  am  looking.  Tests  have  shown 
a  slight  trace  of  sugar  on  three  mornings  since  October  8 
last;  all  other  times  absolutely  sugar-free.  My  weight 
doesn't  change  at  all — if  anything  I  have  gotten  very  slightly 
lighter.  I  weigh  from  124^  to  125|  pounds.  I  still  stick 
absolutely  rigidly  to  my  routine,  but  1  have  gotten  up  to 
30  grams  carbohydrate  per  diem — that  is,  on  the  last  five 
days  of  the  week  I  take  30 — rest  of  diet  the  same.  The  last 
three  weeks  I  have  been  taking  15  grams  oatmeal  for  break- 
fast on  Monday,  Tuesday,  Thursday,  Friday  and  Saturday 
mornings,  Wednesday  all  carbohydrate  in  5  per  cent,  vege- 
tables and  cream,  Sunday  (fast  day)  all  carbohydrate  in 
5  per  cent,  vegetables." 

That  this  improvement  continues  is  evident  from  another 
letter  of  October  12,  1917. 

"We  had  a  patriotic  golf  match  here  last  Saturday  and 
Monday  against  the  rival  golf  club  here.     I  was  chosen  to 

play  2d  for  the and  my  opponent  and  I  came  out 

even  in  both  our  matches,  one  over  our  course  and  the  other 

over  the .     I  am  sending  you  a  newspaper  clipping 

of  the  last  game  at ,  just  to  let  you  see  that  there  is 

some  life  in  the  old  dog  yet.    Since  our  game  Mr.  

won  the  club  championship  of  the . 


MODERATELY  SEVERE  AXD  SEVERE  DIABETES     85 

"I  keep  very  well,  as  you  may  surmise  from  the  above, 
sugar-free  all  the  time.  I  stick  to  the  same  old  routine — 
30  to  31  grams  carbohydrate  per  diem.  I  gave  up  the  orange, 
as  I  really  prefer  the  5  per  cent,  vegetables,  and  I  thought 
that  I  took  the  vegetables  better.  I  had  a  fine  five  days 
the  end  of  September,  up  in  the  woods,  trout  fishing,  had 
good  weather  and  very  good  fishing.  I  managed  to  keep 
sugar-free  all  the  time,  although  I  had  a  good  appetite  and 
took  lots  to  eat." 

February,  1918,  the  patient  continued  in  good  condition, 
sugar-free  with  tolerance  as  before. 

In  what  follows  the  general  principles  underlying  the 
treatment  of  moderately  severe  and  severe  cases  of  diabetes 
are  explained.  It  will  be  seen  that  there  are  many  means 
by  which  the  urine  of. a  diabetic  patient  may  be  freed  from 
sugar,  but  that  the  simplest  of  all  is  by  fasting,  and  to  this 
all  other  methods  converge.  If  fasting  for  a  day  or  two 
appears  inadvisable,  the  simple  omission  of  fat,  which  mate- 
rially reduces  the  nutritive  value  of  the  diet,  may  render 
the  patient  sugar-free.  Formerly,  physicians  endeavored 
to  get  their  patients  sugar-free  by  the  reduction  of  carbo- 
hydrate in  the  diet,  at  the  same  time  immediately  increasing 
the  fat  and  protein  to  make  up  for  the  calories  thus  lost. 
Various  dangers  attended  this  practice,  and  at  present  it  is 
generally  abandoned.  The  method  now  adopted  to  free  the 
urine  of  sugar  is  designed  to  accomplish  this  end  without 
any  risk  to  the  patient.  It  is  brought  about  either  by  com- 
plete fasting  or  by  the  withdrawal  of  fat  from  the  diet,  and 
the  subsequent  reduction  of  carbohydrate  and  protein  to  a 
point  at  which  the  patient  no  longer  voids  sugar  in  the  urine. 
Frequently  I  am  in  the  habit  of  combining  both  methods, 
for  it  so  often  happens  that  by  the  adoption  of  the  plan  about 
to  be  described  under  "Preparation  for  Fasting"  that  a 
patient  becomes  sugar-free  within  a  few  days,  and  free  from 
acid  poisoning  if  that  were  present.  By  methods  like  the 
above  alkalis  are  unnecessary,  and,  indeed,  I  believe  if  they 
are  given  that  they  do  harm.  In  the  following  paragraphs 
in  italics  the  plan  is  summarized: 


86 


DETAILS  OF  DIABETIC  TREATMENT 


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MODERATELY  SEVERE  AND  SEVERE  DIABETES     87 

Preparation  for  Fasting. — In  severe,  long-standing, 
complicated,  obese,  and  elderly  cases,  as  well  as  in  all  cases 
with  acidosis,  or  in  any  case  if  desired,  without  otherwise 
changing  habits  or  diet,  omit  fat,  offer  two  days  omit  protein, 
and  then  halve  the  carbohydrates  daily  until  the  patient  is  taking 
only  10  grams;  then  fast.    In  other  cases  begin  fasting  at  once. 

Fasting. — Fast  four  days,  unless  earlier  sugar-free.  Allow 
water  freely,  tea,  coffee,  and  thin,  clear  meat  broths  as  desired. 

It  is  important  for  the  patient  to  observe  how  his  physician 
frees  the  urine  from  sugar  in  his  particular  case,  because 
later,  if  sugar  should  return,  he  should  follow  the  same  plan 
by  himself. 

An  example  of  fasting  treatment  is  shown  in  Table  23. 
This  patient  was  twenty-two  years  of  age  and  had  previously 
been  accustomed  to  a  low  diet,  but  had  neglected  treatment, 
and  returned  for  hospital  care  with  4.4  per  cent,  of  sugar 
and  in  a  serious  condition  with  much  acid  poisoning.  This 
is  shown  by  the  diacetic  acid  in  the  urine  being  recorded 
-f-  +  +,  four  +  signs  (+  +  +  +)  being  the  maximum 
according  to  my  scale.  It  will  be  observed  that  during  one 
day  of  fasting  the  quantity  of  sugar  dropped  from  97  to  13 
grams,  and  the  percentage  of  sugar  to  1.2  per  cent.  During 
the  second  day  of  fasting,  8  grams  of  sugar  were  excreted, 
merely  a  trace  on  the  fourth  da}',  and  the  fifth  day  of  fasting 
made  the  patient  sugar-free. 

Table  24  shows  how  Case  No.  938,  a  child,  aged  two  years 
and  four  months,  became  sugar-free  in  two  days  with  a 
moderately  restricted  diet  for  the  first  day,  and  with  fasting 
for  the  second  day. 


Table  24, 


-Case  No.  93S.     Aged  Two  Years,  Four  Months. 
Onset  September,  1915. 


Date. 

Urine. 

Diet. 

Diacetic  acid. 

Sugar,  per  cent. 

1915. 
October        25 
October  25-26 
October  26-27 

0 
0 

+ 

7.6 

3.2 

0 

Diet   unrestricted. 

Diet  moderately  restricted. 

Fasting. 

88  DETAILS  OF  DIABETIC  TREATMENT 

It  will  be  observed  that  diacetic  acid  appeared  October 
26  and  27.  In  1915  I  did  not  appreciate  the  necessity  of 
completely  omitting  fat  prior  to  fasting.  I  doubt  if  this 
appearance  of  diacetic  acid  would  occur  at  present,  because 
during  the  last  two  years  measures  taken  for  the  safety  of 
the  patient  at  the  beginning  of  treatment  have  increased 
enormously. 

One  of  the  most  satisfactory  cases  which  I  have  treated 
was  a  man,  Case  No.  1237,  aged  thirty-nine  years,  who  looked 
like  a  severe  diabetic,  but  proved  to  be  a  moderate  one, 
with  whom  the  following  simple  schedule  of  diet  worked 
admirably. 

It  will  be  seen  that  the  patient  did  not  fast  at  all,  main- 
tained a  high  quantity  of  protein  in  his  diet,  and  yet  he 
became  sugar-free  on  the  seventh  day  of  treatment  without 
the  development  of  acid  poisoning.  Although  he  did  not 
enter  the  hospital,  he  came  to  the  office  each  day  until  the 
urine  was  sugar-free.  The  case  is  all  the  more  remarkable 
because  the  duration  of  the  disease  before  treatment  was  a 
year  and  a  half.  In  consequence  of  his  lack  of  treatment, 
his  weight  had  fallen  from  210  pounds  to  142  pounds.  (Com- 
pare this  case  with  Case  No.  653,  described  in  Part  I,  Chapter 
2,  p.  22,  for  whom  treatment  was  begun  early.)  When  first 
seen  the  sugar  in  the  twenty-four-hour  quantity  of  urine  of 
(  ase  No.  1237  was  336  grams.  The  directions  given  the 
patient  may  be  summarized  as  follows: 

1.  Take  \  pound  (240  grams)  5  per  cent,  vegetables,  \ 
pound  (120  grams)  fish,  and  one  small  orange  at  each  meal 
for  two  days. 

2.  On  the  third  day  omit  half  and  on  the  fourth  day  all 
the  orange. 

3.  When  sugar-free,  exchange  \  pound  (4  oz.  =  120  g.) 
fish  for  3  ounces  (90  g.)  meat  and  next  replace  another  \ 
pound  fish  by  4  eggs. 

4.  Then  replace  2  eggs  with  2  ounces  (60  g.)  bacon  and 
subsequently  add  \  ounce  (15  g.)  butter  a  day  for  two  days, 
to  be  followed  every  other  clay  by  the  addition  of  1  ounce 
(30  c.c.)  of  20  per  cent,  cream  until  3  ounces  are  taken. 


MODERATELY  SEVERE  AND  SEVERE  DIABETES     89 


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DETAILS  OF  DIABETIC  TREATMENT 


5.  Similarly,  thereafter  every  other  day  add  one-half  an 
orange  until  one-half  is  taken  at  a  meal  and  from  then  on 
every  other  day  1  ounce  potato  until  as  much  as  desired  is 
taken,  or  sugar  appears. 

Case  No.  979,  a  woman,  aged  forty-nine  years,  developed 
diabetes  at  the  age  of  thirty-two.  When  I  first  saw  her 
seventeen  years  later,  January  26,  1916,  she  showed  7.4 
per  cent,  of  sugar  and  no  diacetic  acid.  It  will  be  seen  from 
Table  26  how  she  became  sugar-free  without  the  develop- 
ment of  acidosis  by  the  elimination  of  fat  and  the  restriction 
of  protein,  followed  by  the  gradual  diminution  of  carbo- 
hydrate. 

Table  26. — Case  No.  979,  of  Seventeen  Years'  Duration,  Illus- 
trates (1)  How  Preparatory  Treatment  Makes  Fasting 
Unnecessary  and  (2)  Renders  the  Urine  Sugar-free 
without  the  Appearance  of  Acid  Poisoning. 


Urine. 

Diet  in  grams. 

Dietary  prescriptions  in  grams. 

Sugar. 

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Trace 

0 

Fasting. — Fasting  is  never  so  rigorous  as  doctors  or  patients 
expect.  Patients  are  more  ready  to  undergo  it  than  physi- 
cians to  prescribe  it.  Quite  as  often  it  is  as  much  a  relief 
to  the  patient  as  it  is  discomfort.  This  is  in  part  due  to  the 
gradual  decrease  in  thirst  and  frequent  urination.  Headache 
occurs  less  frequently  than  would  be  expected,  and  is  usually 
dispelled  by  a  cup  of  coffee.  Nausea  almost  never  occurs 
unless  a  patient  is  given  alkali  or  alcohol.     Children  bear 


MODERATELY  SEVERE  AND  SEVERE  DIABETES     91 

fasting  more  easily  than  adults.  Case  No.  799  with  onset 
at  eighty-three,  shunned  it  and  rightly,  but  she  became 
sugar-free  and  now,  two  years  later,  is  vigorous,  remains 
sugar-free  and  is  actually  able  to  eat  apple  pie  and  put 
sugar  in  her  coffee  without  sugar  occurring  in  the  urine.  It 
is  always  desirable  to  avoid  fasting  in  the  old,  and  this  can 
be  accomplished  usually  by  the  help  of  preparatory  treat- 
ment. Fasting  does  not  seem  like  fasting  to  the  patients 
when  they  receive  coffee,  tea,  cracked  cocoa,  cocoa  shells 
and  broths,  and  are  given  an  unlimited  supply  of  water. 
Warm  drinks  are  preferable.  If  the  quantity  of  urine,  as  it 
often  does,  falls  to  less  than  normal,  the  patients  are  urged 
to  drink  water  freely.  Clear  meat  broths  are  a  great  satis- 
faction. An  analysis  of  the  1220  c.c.  of  broths  taken  by 
Case  No.  765  during  three  days,  showed  the  total  amount 
of  calories  therein  contained  to  be  negligible.  Contrary  to 
my  experience  with  digestive  cases,  broths  do  not  stimulate 
the  appetite  in  fasting  diabetics;  they  relieve  it.  The  advan- 
tage of  broths  is  probably  due  in  part  to  this,  but  to  a  con- 
siderable extent  to  the  patient  receiving  salt  by  which  he 
•may  maintain  the  equilibrium  of  body  fluid. 

Patients  need  not  be  kept  abed  during  fasting,  neither 
should  they  be  forced  to  be  up  all  day.  Reclining  in  a  steamer 
chair  requires  no  more  exertion  than  rest  in  bed.  Remember 
what  happens  to  an  old  man  who  is  suddenly  confined  to 
bed,  and  the  discomfort  which  follows  confinement  after  a 
fracture.  Do  not  force  a  temperate  man  to  drink  against 
his  will.  Patients  should  be  afforded  diversion  by  brief 
visits  from  friends,  walking  short  distances,  easy  handiwork, 
playing  games,  letter  writing,  and  reading.  In  general, 
they  are  glad  to  rest  for  the  greater  part  of  the  first  day  of 
the  fast,  but  upon  each  succeeding  day  I  have  noticed  that 
they  are  desirous  to  increase  the  amount  of  exercise.  An 
advantage  which  the  omission  of  fat  from  the  diet  affords 
is  the  rest  which  is  given  to  the  digestive  tract.  Former 
treatment,  which  increased  the  fat  in  the  diet,  was  the 
converse  of  this,  and  frequently  led  to  vomiting,  with  the 
result  that  patients  on  the  verge  of  coma  fell  into  it.  In 
every  way  seek  to  prevent  worry  on  the  patient's  part,  and 


02  DETAILS  OF  DIABETIC  TREATMENT 

from  the  start  give  them  to  understand  that  they  are  at 
school  rather  than  at  hospital. 

Patients  upon  a  low  diet  should  be  guarded  from  infections. 
If  a  nurse  has  a  cold  she  should  be  relieved  from  duty,  cer- 
tainly from  duty  near  diabetics.  For  this  reason,  when  on  a 
low  diet,  patients  should  keep  out  of  street  cars  and  shim 
congregations  of  people. 

It  is  surprising  how  variable  is  the  period  required  to 
render  the  urine  sugar-free.  Frequently  a  urine  which  con- 
tains 7  per  cent,  of  sugar  becomes  free  from  sugar  after  fast- 
ing for  four  meals,  and,  conversely,  a  urine  with  only  .3  per 
cent,  of  sugar  may  still  retain  traces  after  the  patient  has 
been  deprived  of  food  for  three  or  four  days.  Cases  present- 
ing acidosis  I  believe  invariably  require  longer  to  become 
free  from  sugar.  In  general,  cases  seen  soon  after  onset 
become  sugar-free  promptly,  whereas  the  reverse  is  true  for 
those  of  long  duration.  However,  Case  No.  733,  age  at  onset 
seventeen  years,  was  fasted  twenty-six  months  later,  when 
he  showed  6.6  per  cent,  of  sugar  and  became  sugar-free  in 
two  days.  The  explanation  in  this  instance  was  apparently 
the  fact  that  the  case  was  remarkably  mild,  being  of  the 
obesity  type;  in  fact,  the  patient's  highest  weight — 196 
pounds — was  reached  when  he  first  came  under  observation, 
and  during  the  preceding  twenty-six  months  he  had  gained 
twenty-six  pounds.  Children  showing  large  amounts  of 
sugar  have  also  become  sugar-free  very  promptly  when  the 
duration  has  been  only  a  few  weeks.  Cases  of  long  standing 
appear  to  become  sugar-free  more  quickly  with  preparatory 
treatment  than  with  an  immediate  fast.  This  is  probably 
due  to  the  avoidance  of  acidosis.  Rarely  is  it  necessary 
for  a  patient  to  fast  more  than  a  few  days,  and  I  usually 
prefer,  after  four  days  of  fasting,  if  the  urine  still  contains 
sugar,  to  feed  the  patient  for  two  days  and  then  fast  again. 
The  general  rule  which  I  have  as  a  guide  is  as  follows: 

Intermittent  Fasting. — If  glycosuria  persists  at  the  end 
of  four  days,  give  1  gram  protein  or  0.5  gram  carbohydrate  per 
kilogram  body  weight  for  two  days  and  then  fast  again  for  three 
days  unless  earlier  sugar-free.  If  glycosuria  remains,  repeat 
and  then  fast  for  one  or  two  days  as  necessary.    If  there  is  still 


MODERATELY  SEVERE  AND  SEVERE  DIABETES     93 

sugar,  give  protein  as  before  for  four  days,  then  fast  one,  and 
then  gradually  increase  the  periods  of  feeding,  one  day  each 
time,  until  fas-ting  one  day  each  week.  I  have  seen  no  uncom- 
plicated ease  fail  to  get  sugar-free  by  this  method. 

Carbohydrate  Tolerance. — Inspection  of  the  various 
charts  above  cited  will  show  that  when  the  twenty-four-hour 
quantity  of  urine  has  been  free  from  sugar  it  is  the  custom 
to  increase  the  carbohydrate,  and  this  is  usually  done  to  the 
point  at  which  sugar  returns.  In  this  way  the  tolerance  of 
the  patient  for  carbohydrate  is  determined.  My  rule  is: 
When  the  twenty-four-hour  urine  is  free  from  sugar,  give  5  to 
10  grams  carbohydrate  (150  to  300  grams  of  5  per  cent,  vege- 
tables) and  continue  to  add  5  to  10  grams  carbohydrate  daily 
up  to  50  grams  or  more  until  sugar  appears.  The  carbohydrate 
is  generally  given  in  the  form  of  5  per  cent,  vegetables, 
choosing  those  which  are  especially  bulky.  A  plateful  of 
lettuce  appeals  much  more  to  the  patient  than  a  small 
saucer  of  string  beans.  When  a  mixture  of  5  per  cent, 
vegetables  is  given,  one  can  be  quite  sure  that  the  average 
content  of  carbohydrate  is  not  more  than  3  per  cent.,  or 
•approximately  5  grams  for  the  150  grams  prescribed,  and 
for  convenience  this  is  reckoned  as  1  gram  of  carbohydrate 
for  each  30  grams  (1  ounce).  This  small  amount  of  food,  of 
course,  has  little  nutritive  value,  but  is  enough  to  break  the 
fast.  Upon  succeeding  days,  5,  10  or  even  more  grams  of 
carbohydrate,  varying  with  the  severity  of  the  case,  are 
added  daily  until  sugar  returns  or  the  approximate  quantity 
is  reached  which  it  appears  probable  the  patient  will  tolerate. 
It  should  be  borne  in  mind  that  a  patient  fasting  or  on  a  very 
low  diet  often  shows  an  apparent  tolerance  for  carbohydrate 
far  in  excess  of  that  which  he  would  have  shown  if  the  neces- 
sary protein  and  fat  in  his  diet  were  simultaneously  ingested. 

Following  the  trial  with  5  per  cent,  vegetables,  one  can 
proceed  to  the  10  per  cent,  group  and  these  can  be  empir- 
ically reckoned  as  containing  6  per  cent,  carbohydrate  or 
approximately  twice  that  of  the  5  per  cent,  group,  or  5  grams 
carbohydrate  for  75  grams  vegetables.  From  this  point 
onward  the  addition  of  carbohydrate  can  be  made  according 
to  the  desire  of  the  patient.    The  foods  commonly  employed 


94  DETAILS  OF  DIABETIC  TREATMENT 

in  determining  the  tolerance  for  carbohydrate  are :  5  per  cent, 
vegetables,  oranges,  oatmeal  and  potato.  With  children 
one  often  makes  the  mistake  of  increasing  the  carbohydrate 
too  rapidly,  forgetting  the  fact  that  5  grams  of  carbohydrate 
to  a  child  weighing  20  kilograms  is  in  the  same  proportion 
as  15  grams  of  carbohydrate  to  an  individual  of  60  kilograms. 

The  increase  in  carbohydrate  is  also  illustrated  by  Case 
No.  1209,  Table  27,  whose  chart,  however,  shows  how  sugar 
sometimes  appears  in  the  urine  when  if  the  doctor's  advice 
had  been  followed  it  would  have  remained  absent.  This 
little  boy  ate  candy,  and  though  the  quantity  of  sugar 
in  his  urine  had  fallen  to  1  gram  on  January  3-4,  it  re- 
quired two  days  of  fasting  following  his  use  of  candy  for  it 
to  disappear.  Once  again  he  broke  rules  and  fasting  was 
necessary.  Gradually  he  learned  his  lesson,  at  least  tem- 
porarily, and  left  the  hospital  with  a  tolerance  for  37  grams 
of  carbohydrate  and  50  calories  per  kilogram  body  weight. 

Protein  Tolerance. — When  the  urine  has  been  sugar-free 
for  three  days,  add  about  20  grams  protein  and  thereafter  15 
grains  protein  daily  in  the  form  of  egg-white,  fish  or  lean  meat 
(chicken)  until  the  patient  is  receiving  1  gram  protein  per 
kilogram  body  weight  or  less  if  the  carbohydrate  tolerance  is 
zero. 

Thirty  grams  of  fish  or  an  egg  of  average  size  contain 
approximately  6  grams  of  protein  and  30  grams  of  lean  meat 
contain  approximately  8  grams.  The  white  of  an  egg  con- 
tains 3  grams  of  protein.  By  this  arrangement  a  patient 
weighing  60  kilograms  would  be  taking,  within  six  days  from 
the  time  he  became  sugar-free,  1  gram  of  protein  per  kilo- 
gram body  weight.  This  quantity  is  quite  satisfying  to  all 
except  children — in  fact,  it  is  astonishing  to  me  to  find  how 
few  patients  care  to  take  as  much  as  1.5  grams  of  protein 
per  kilogram  body  weight.  Children,  however,  crave  and 
need  considerably  more,  and  indeed  take  with  avidity  as 
much  as  2  to  3  grams  protein  per  kilogram  body  weight. 

Fish  is  especially  desirable  in  the  early  days  of  protein 
feeding  because  it  contains  so  little  fat.  Cod,  haddock  and 
flounder,  for  example,  contain  less  than  1  per  cent. 


MODERATELY  SEVERE  AND  SEVERE  DIABETES     95 


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96  DETAILS  OF  DIABETIC  TREATMENT 

The  .advantage  of  giving  and  increasing  protein  simul- 
taneously with  the  determination  of  the  carbohydrate 
tolerance  is  that  one  approaches  more  nearly  normal  condi- 
tions. What  the  physician  is  after  is  to  determine  the  carbo- 
hydrate tolerance  while  the  patient  is  on  a  full  diet  and  not 
the  tolerance  for  carbohydrate  alone.  On  the  other  hand,  I 
freely  admit  that  a  higher  carbohydrate  tolerance  can  be 
attained  when  the  addition  of  protein  following  the  prelimi- 
nary fasting  is  deferred  until  the  actual  carbohydrate  toler- 
ance is  learned  in  the  absence  of  protein  and  fat.  Naturally 
the  method  adopted  will  vary  somewhat  with  each  patient. 

There  are  very  few  patients  who  will  not  bear  at  the  outset 
as  much  as  1  gram  of  protein  per  kilogram  body  weight,  and 
I  am  very  loath  to  allow  the  protein  to  remain  permanently 
below  this  figure.  This  can  be  avoided  by  still  further 
restricting  the  carbohydrate,  either  temporarily  or  per- 
manently. It  is  always  necessary  to  remember  that  one 
food  which  the  diabetic  patient  cannot  do  without  is  protein, 
and  to  it  everything  else  must  be  subordinated.  More  and 
more  I  believe  we  shall  strive  to  spare  body  protein. 

Fat  Tolerance. — The  work  of  Professor  Bloor  and 
1  )r.  Gray  in  Boston  and  that  of  workers  at  various  other 
laboratories  has  provided  us  with  a  reliable  indicator 
for  the  tolerance  of  the  patient  for  fat  by  means  of  the 
estimation  of  fat  in  the  blood.  As  yet  the  test  is  too  com- 
plicated for  general  use,  but  for  those  who  have  access  to  a 
laboratory  it  is  perfectly  practical.  For  those  not  in  a  posi- 
tion to  employ  Bloor's  fat  method  there  are  two  indirect 
methods  of  determining  fat  tolerance,  namely,  signs  of 
acidosis  and  the  appearance  of  sugar  in  the  mine  (glycosuria). 
So  long  as  these  exist  the  fat  must  be  kept  low.  While  testing 
the  protein  tolerance  a  small  quantity  of  fat  is  included  if, 
in  addition  to  whites  of  eggs  and  lean  fish,  meat  is  given. 
Formerly  I  thought  this  advantageous,  and  such  small 
quantities  of  fat  certainly  do  no  harm  in  the  milder  cases. 
In  fact  the  same  rule  holds  for  the  testing  of  the  carbohydrate 
and  protein  tolerance  in  the  presence  of  fat  as  has  been  said 
for  protein  alone.  There  are,  on  the  other  hand,  two  impor- 
tant reasons  why  J'at  should  not  be  given  to  the  diabetic 


MODERATELY  SEVERE  AXD  SEVERE  DIABETES     97 

patient  immediately  upon  his  becoming  sugar-free:  (1)  by  the 
omission  of  fat,  partial  fasting  is  continued  and  thereby 
the  patient  is  gaining  a  tolerance  for  carbohydrate,  and  (2) 
the  continued  omission  of  fat  is  beneficial  in  counteracting  the 
last  vestige  of  acid  poisoning,  or  preventing  the  appear- 
ance of  acid  poisoning,  which  might  easily  occur  in  a  diabetic 
patient  whose  metabolism  has  not  become  accustomed  to  so 
low  a  quantity  of  carbohydrate.  But.  as  soon  as  the  patient 
has  received  the  essential  gram  of  protein  per  kilogram 
body  weight  the  fat  in  the  diet  should  be  increased.  If  the 
patient  is  one  in  whom  acidosis  has  been  an  essential  factor, 
or  if  the  patient  is  obese,  the  fat  should  be  increased  slowly, 
and  for  such  a  patient  an  increase  of  5  to  10  grams  a  day 
may  be  all  that  he  can  take  without  the  recurrence  of  a  posi- 
tive ferric  chloride  reaction  in  the  urine.  Cases  which  have 
shown  little  acidosis  may  easily  be  allowed  an  increase  of 
2o  grams  fat  daily,  and  for  such  cases  this  is  desirable, 
because  it  rapidly  brings  the  total  caloric  value  of  the  diet 
up  to  a  normal  figure.  Naturally,  patients  in  whose  treat- 
ment a  loss  of  weight  is  desired  would  be  given  smaller 
quantities  of  fat. 

The  rule  which  I  have  for  myself  is  as  follows : 

Add  no  fat  until  the  protein  reaches  1  gram  per  kilogram 
body  weight  (unless  the  protein  tolerance  is  below  this  figure) 
and  the  carbohydrate  tolerance  has  been  determined,  but  then 
add  5  to  25  grams  daily,  according  to  previous  acidosis  until 
the  patient  ceases  to  lose  weight  or  receives  in  the  total  diet 
about  30  calories  per  kilogram  body  weight. 

Reappearance  of  Sugar. —  The  return  of  sugar  demands 
fasting  for  twenty-four  hours  or  until  sugar-free.  Resume  the 
farmer  diet  gradually,  adding  fat  last  in  order  to  maintain  as 
high  a  carbohydrate  tolerance  as  possible,  sacrificing  body 
weight  for  this  purpose.  This  rule  should  be  inflexibly  fol- 
lowed, especially  with  children. 

In  hospitals  it  simplifies  the  treatment  enormously. 
As  soon  as  it  is  understood  that  the  reappearance  of  sugar 
means  a  fast  until  sugar  disappears  from  the  twenty-four- 
hour  quantity  of  urine  there  is  little  tendency  to  break  over 
the  diet.  Furthermore,  most  patients  are  thrifty  enough 
7 


98  DETAILS  OF  DIABETIC  TREATMENT 

to  see  the  disadvantage  of  paying  their  board  with  no  return. 
The  rule  must  be  rigidly  enforced  with  children,  because 
with  them  disobedience  means  death.  When  a  patient  has 
been  made  sugar-free  by  a  preliminary  fast,  absence  of  food 
for  twenty-four  hours  will  almost  invariably  be  sufficient 
to  free  the  urine  at  once  if  the  sugar  returns.  This  will  not 
be  the  case  unless  the  presence  of  glucose  is  promptly  detected, 
and  hence  the  necessity  for  the  patient  to  examine  his  twenty- 
four-hour  urine  daily.  Following  this  accessory  fasting  day, 
the  previous  diet  of  the  patient  may  be  gradually  resumed, 
making  every  endeavor  to  regain  the  former  tolerance  for 
carbohydrate  by  slowly  increasing  the  quantity  of  fat. 
Great  care  should  be  exercised,  more  indeed  than  I  have 
often  taken,  not  to  break  down  the  tolerance  a  second  time. 

Months  rather  than  weeks  should  intervene  before  the 
final  amounts  of  carbohydrate,  protein  and  fat,  reached  the 
second  time,  equal  the  quantity  of  carbohydrate  taken  when 
sugar  reappeared.  I  have  always  been  much  impressed  by 
the  success  of  Drs.  Janeway  and  Mosenthal  in  the  treatment 
of  one  of  their  patients,  because  the  patient  had  been  taught 
to  keep  the  carbohydrate  so  low  that  sugar  did  not  reappear 
though  he  was  away  from  their  supervision  for  a  period  of 
months. 

Patients  often  get  into  trouble  by  their  failure  to  energetic- 
ally grapple  with  the  reappearance  of  sugar.  One  day  of 
fasting  will  accomplish  far  more  than  many  days  of  a  moder- 
ately low  diet.  It  is  a  mistake  for  any,  save  the  most  highly 
trained  patients,  to  attempt  to  meet  such  a  situation  without 
medical  advice. 

Case  No.  804,  described  on  page  80  illustrates  this  well, 
for  it  is  perfectly  evident  that  he  was  an  intelligent  patient, 
and  yet  grew  steadily  worse  until  he  returned  for  the  second 
period  of  treatment  at  the  hospital. 

Another  instance  is  Case  No.  1279,  who  reached  a  toler- 
ance in  April,  1917,  at  the  hospital,  for  78  grams  carbohydrate, 
63  grams  protein  and  109  grams  fat,  with  a  blood  sugar  at 
this  time  of  0.12  per  cent.  In  the  autumn  of  the  same  year 
sugar  repeatedly  recurred,  and  he  was  unable  to  become 
sugar-free  at  home.    After  a  stay  of  a  few  weeks  at  the  hos- 


MODERATELY  SEVERE  AND  SEVERE  DIABETES     99 

pital  he  was  discharged  with  a  tolerance  for  65  grams  carbo- 
hydrate, 74  grams  protein,  98  grams  fat  and  blood  sugar  of 
0.14  per  cent. 

Still  another  patient,  Case  No.  1265,  shows  the  improve- 
ment of  medical  supervision.  This  patient,  a  woman,  aged 
fifty-seven  years,  left  the  Corey  Hill  Hospital  on  May  5, 
1917,  with  a  tolerance  for  30  grams  carbohydrate,  58  grams 
protein  and  119  grams  fat,  and  a  blood  sugar  under  0.1 
per  cent.  Until  the  summer  she  did  well,  but  in  the 
early  autumn  apparently  finding  the  urine  normal,  steadily 
increased  her  diet,  yet  her  condition  was  not  satisfactory 
to  herself  or  her  friends.  Upon  the  return  of  her  doctor  he 
discovered  that  the  Benedict  solution  she  had  been  using 
was  inaccurately  made  up  and  for  over  a  month  sugar  had 
undoubtedly  been  present  in  the  urine.  Under  hospital 
treatment  she  was  discharged  in  two  weeks  with  a  tolerance 
for  33  grams  carbohydrate,  61  grams  protein  and  81  grams 
fat,  with  a  blood  sugar  of  0.14  per  cent. 

Weekly  Fast  Days. —  Whether  sugar  reappears  in  the 
urine  or  not  it  is  desirable  upon  one  day  each  week  to  rest  that 
function  of  the  body  which  controls  the  assimilation  of  sugar 
by  either  a  complete  fast  day  or  a  diet  of  low  caloric  value.  My 
plan  is  patterned  on  the  following  rule:  Whenever  the  tolerance 
is  less  than  20  grams  carbohydrate,  fasting  should  be  practised 
one  day  in  seven;  when  the  tolerance  is  over  20  grams  carbo- 
hydrate, cut  the  diet  in  half  on  one  day  each  week  ("  half-day"). 

This  is  a  revival  of  an  old  practice  used,  I  understand, 
many  years  ago  by  Dr.  Austin  Flint,  of  New  York,  who 
fasted  and  kept  abed  his  diabetic  patients  on  Sundays,  and 
in  fact  I  believe  von  Noorden  terms  such  weekly  fast  days 
"Diabetic  Sundays." 

The  benefit  which  the  older  clinicians  derived  from  the 
use  of  one  day's  fast  in  seven  in  the  treatment  of  their 
diabetic  patients  should  ever  be  borne  in  mind.  Case  No. 
1062,  now  under  observation,  who  contracted  diabetes 
twenty-six  years  ago,  possibly  in  connection  with  gall- 
stones, tells  me  that  at  that  period  her  physician,  Dr. 
Randall,  of  Topsfield,  Mass.,  often  told  her  to  go  without 
food,  save  broths,  for  several  days  in  succession,  and  that 


100  DETAILS  OF  DIABETIC  TREATMENT 

she  would  follow  this  advice.  Her  severe  symptoms  of 
diabetes  subsided  at  the  end  of  four  years.  Recently  the 
quantity  of  sugar  has  been  slight.  Her  tolerance  on  June  1, 
1916,  reached  116  grams  carbohydrate.  The  advantage 
of  this  restricted  diet  day  each  week  is  partly  inherent  in 
the  fast  or  restricted  diet,  but  to  a  considerable  extent  it  is 
due  to  the  attention  of  the  patient  being  sharply  called  to 
his  disease  one  day  in  seven,  and  the  recollection  which  it 
awakens  in  his  mind  of  his  condition  before  treatment  began 
and  the  difficulties  which  may  have  originally  accompanied 
becoming  sugar-free.  Some  exceptions  to  the  above  rules 
may  be  mentioned :  for  example,  elderly  patients  bear  fasting 
poorly,  and  when  they  remain  sugar-free  upon  a  rigid  diet 
containing  only  10  grams  of  carbohydrate  it  is  my  impression 
that  it  is  better  to  simply  restrict  the  calories  of  the  diet 
one-half  on  one  day  each  week  rather  than  to  institute  an 
absolute  fast.  With  such  treatment  these  patients  almost 
invariably  gain  in  tolerance  for  carbohydrate.  Children 
become  fretful  upon  a  fast  day,  though  physically  they 
endure  it  well.  If  they  are  allowed  a  few  green  vegetables  in 
addition  to  broths  they  get  along  very  comfortably.  Von 
Noorden  pointed  out  that  the  good  effects  of  a  fast  day 
continued  many  days  beyond  the  actual  fast. 

The  Caloric  Needs  of  the  Patient. — The  total  number  of 
calories  which  a  diabetic  requires  varies  not  only  with  each 
case,  but  varies  with  each  case  each  day.  Schematic  rules 
do  not  hold.  One  must  remember  that  an  individual  trained 
to  be  quiet  and  while  lying  down  can  get  along  with  only 
20  calories  per  kilogram  body  weight  reckoned  per  twenty- 
four  hours,  whereas  the  average  of  a  large  group  of  normal 
men  and  women  at  the  Nutrition  Laboratory,  not  especially 
trained  for  the  test,  consumed  25  calories  per  kilogram  body 
weight  reckoned  also  per  twenty-four  hours.  If  this  varia- 
tion exists  while  at  rest,  how  much  more  it  must  exist  during 
the  various  activities  of  different  individuals.  Furthermore, 
one  must  remember  that  the  number  of  calories  consumed 
per  hour  varies  enormously.  An  individual  weighing  60 
kilos  walking  at  the  rate  of  four  miles  per  hour  would  require 
an  additional  193  calories  for  that  hour  over  the  resting 


MODERATELY  SEVERE  AND  SEVERE  DIABETES     101 

metabolism.  Habits  of  individuals  vary  widely.  Some  are 
quiet  and  some  are  active.  All  these  considerations  should 
be  clearly  borne  in  mind  by  doctors  and  patients  in  order 
not  to  allow  themselves  to  be  held  too  rigidly  by  any  caloric 
fetish. 

Special  Dietetic  Rules  and  Hints. — The  responsibility  for 
the  management  of  the  diet  of  a  diabetic  patient  should 
always  rest  upon  one  individual.  As  a  rule  that  individual 
is  the  patient,  but  at  times  another  member  of  the  house- 
hold. Children  who  are  above  the  age  of  ten  years  should 
be  taught  to  plan  their  own  diet.  They  readily  learn  to  do 
this  and  in  so  doing  make  their  elders  blush.  In  fact,  it  is 
more  important  for  diabetic  children  to  learn  what  and  how 
much  to  eat  than  all  the  knowledge  which  their  schools 
afford,  for  upon  this  information  their  life  depends.  Perhaps 
it  is  because  this  personal  responsibility  is  so  deeply  felt  in 
the  management  of  little  children  that  the  treatment  of 
diabetes  in  them  proceeds  so  uniformly  and  always  produces 
results  so  much  better  than  are  expected.  Eat  too  little 
rather  than  too  much.  With  a  return  to  normal  weight 
sugar  may  appear. 

All  food  must  be  eaten  slowly,  and  the  coarser  the  food 
the  more  thoroughly  it  should  be  masticated. 

If  in  doubt  about  a  food,  let  it  alone  until  you  have  found 
out  whether  it  is  allowed.  Do  not  yield  to  the  temptation 
of  friends  to  break  the  diet,  for  if  this  is  done  the  plan  of 
treatment  is  upset,  a  week's  time  may  be  lost  and  several 
pounds  of  weight  sacrificed.  Sa-called  diabetic  foods  often 
contain  considerable  quantities  of  carbohydrate,  and  usually 
contain  so  much  protein  and  fat  that  they  should  not  be 
taken  by  the  patient  without  due  allowance  for  the  same. 
They  should  not  be  taken  under  any  circumstances  unless 
their  composition  is  known.  Be  especially  careful  to  note 
the  effect  of  any  increase  in  carbohydrate.  The  same  rules 
hold  for  protein.  The  quantity  of  fat  is  generally  regulated 
by  the  patient's  weight. 

The  carbohydrate  in  the  diet  should  be  divided  between 
the  three  meals.  Even  if  the  10  per  cent.,  15  per  cent,  and 
20  per  cent,  vegetables  are  allowed,  vegetables  from  the  5 


102  DETAILS  OF  DIABETIC  TREATMENT 

per  cent,  group  should  be  taken  as  well.  Usually  it  is  allow- 
able to  substitute  for  a  given  quantity  of  5  per  cent,  vege- 
tables one-half  as  much  from  the  10  per  cent,  group,  one- 
quarter  as  much  from  the  15  per  cent.,  or  one-sixth  as  much 
from  the  20  per  cent.  Exchange  vegetables  for  fruit  only 
under  advice.  Remember  it  is  always  possible  to  get  articles 
of  food  which  are  included  in  a  strict  diabetic  diet  for  a  few 
meals,  such  as  eggs,  meat,  butter,  oil  and  even  5  per  cent, 
vegetables,  fresh  or  canned.  One  of  my  cases  who  has  done 
exceptionally  well  has  a  diabetic  garden  and  thus  provides 
liberally  for  his  table  both  summer  and  winter.  Quiet  out- 
door work  agrees  with  diabetic  patients. 

In  case  of  illness  curtail  the  fat  in  the  diet,  and  if  acid 
poisoning  is  shown  by  the  ferric  chloride  reaction,  omit  fat 
entirely. 


CHAPTER   IV. 

ACID  INTOXICATION— ACIDOSIS— DIABETIC 
COMA. 

Acid  intoxication  is  the  bugbear  of  doctor  and  patient. 
Formerly  more  than  six  of  every  ten  diabetic  patients 
succumbed  to  it,  but  now  it  is  much  less  frequent.  The  acid 
intoxication  (acid  poisoning,  or  technically  termed  acidosis) 
of  diabetic  patients  diners  in  no  respect  from  the  acidosis 
of  normal  individuals,  easily  to  be  produced  within  three 
days  by  the  omission  of  carbohydrate  from  the  diet.  The 
ferric  chloride  (diacetic  acid)  reaction  will  then  appear  just 
as  in  a  severe  diabetic,  and  if  at  the  same  time  the  quantity 
of  fat  is  increased,  a  type  of  acidosis  will  be  caused,  so  severe 
as  to  threaten  the  life  of  the  individual.  When,  however, 
the  healthy  body  is  gradually  accustomed  to  live  upon  a 
diet  low  in  carbohydrate,  acidosis  is  avoided.  The  same 
course  of  events  takes  place  in  diabetes.  In  severe  cases 
when  all  the  carbohydrate  of  the  diet  appears  in  the  urine 
as  sugar,  the  diabetic  patient,  although  eating  carbohydrate, 
is  exactly  like  the  normal  individual  deprived  of  his  customary 
carbohydrate.  If  fat  in  undue  quantities  is  given  to  a  severe 
case  of  diabetes,  under  these  circumstances  diabetic  coma 
may  result.  This  did  result  when  years  ago  we  physicians, 
doing  the  best  we  knew,  deprived  patients  of  their  carbo- 
hydrates in  order  to  make  them  sugar-free,  and  at  the  same 
time,  in  order  to  enable  them  to  maintain  their  weight,  we 
markedly  increased  fat  and  protein  to  make  up  the  calories 
omitted  as  carbohydrate.  From  what  has  been  already 
written,  it  can  be  seen  that  now  we  know  better. 

Patients  are  first  of  all  deprived  of  fat,  without  other 
change  in  their  dietary  habits,  in  order  to  take  away  the 
great  danger  of  acid  intoxication,  and  they  subsequently  are 


104  DETAILS  OF  DIABETIC  TREATMENT 

either  made  sugar-free  by  gradual  reduction  of  carbohydrate 
and  protein  or  by  simply  fasting.  When  sugar-free  and  one 
begins  to  increase  the  diet,  the  fat  is  the  food  element  to 
be  given  last  of  all. 

Even  when  patients  already  showing  acidosis  come  for 
treatment,  it  usually  disappears  under  the  above  plan. 
Should  the  acidosis  be  severe  the  following  rules,  now  in 
force  for  my  cases  at  the  New  England  Deaconess  and  Corey 
Hill  Hospitals,  are  suggested.  I  recommend  that  all  patients 
become  familiar  with  these  rules,  and  thus  anxiety  over  acid 
poisoning  will  disappear.  This  plan  of  treatment  seldom 
fails.  Indeed,  since  I  have  established  it  as  a  routine  method 
of  procedure,  worry  about  acid  poisoning  in  my  patients  has 
largely  decreased,  and  evening  visits  to  the  hospitals  are 
eliminated. 

Rules  for  the  Treatment  of  Severe  Acid  Poisoning. 

1.  Nursing. — Provide  a  special  nurse  for  the  patient  for 
both  day  and  night,  and  preferably  one  trained  in  diabetic 
work. 

2.  Bed. — Keep  the  patient  in  bed  and  warm.  Avoid  loss 
of  calories  through  exertion  or  exposure;  if  restless,  protect 
from  becoming  chilled  by  flannel  nightclothes.  Every  effort 
should  be  made  to  allay  nervousness  and  discomfort. 

3.  Care  of  the  Bowels. — Move  the  bowels  by  one  or  more 
enemata.  Cathartics  should  usually  be  avoided  for  fear  of 
causing  diarrhea. 

4.  Administration  of  Liquids. — Give  1000  c.c.  (1  quart)  of 
liquids  within  each  six  hours.  The  liquids  are  to  be  given 
slowly,  and  hot.  Use  coffee,  tea,  thin  broths,  water;  see 
also  5.  If  the  prospect  is  dubious  of  giving  so  much  liquid 
by  mouth,  salt  solution  or  tap  water  is  to  be  given  by  rectum ; 
if  this  resource  fails,  the  nurse  should  call  the  doctor  to  give 
intravenously,  or  if  that  is  impossible,  subcutaneously,  the 
balance  of  the  liter  which  remains  not  given  for  the  period. 
(It  will  seldom  be  found  necessary  to  give  more  than  1000  c.c. 
liquids,  thanks  to  the  avoidance  of  alkalis.)  In  order  to 
secure  the  introduction  of  sufficient  liquid  in  the  first  six 


ACID  INTOXICATION— ACIDOSIS— DIABETIC  COMA     105 

hours,  the  cleansing  enema  at  the  beginning  of  treatment 
should  be  followed  after  half  an  hour  by  an  enema  of  500  c.c. 
salt  solution  (one  tea  spoonful  salt  in  one  pint  of  water)  in 
all  eases  as  a  matter  of  precaution. 

5.  Diet. — If  the  patient  has  been  accustomed  to  the  fasting 
method  of  treatment,  begin  or  continue  the  fast,  but  if  he 
has  been  upon  a  full  diet  omit  the  fat  which  it  contained, 
but  continue  the  same  quantity  carbohydrate  and  protein 
of  the  preceding  days,  giving  at  least  a  gram  of  carbohydrate 
per  kilogram  body  weight  in  the  form  of  strained  orange 
juice  or  gruel  (oatmeal)  made  with  water,  during  the  twenty- 
four  hours.  Of  late  I  have  given  each  six  hours  an  amount 
of  carbohydrate  equal  to  or  slightly  in  excess  of  that  voided 
in  the  urine  during  the  preceding  twenty-four  hours.  Which- 
ever course  is  adopted,  it  is  to  be  followed  until  danger  is 
over.  The  carbohydrate  should  be  given  in  a  form  easily 
tolerated  by  the  stomach,  such  as  carefully  made  gruels, 
orange  juice,  skimmed  milk  or  bread.  Avoid  an  excess  of 
coarse  vegetables. 

6.  Stomach. — If  there  is  evidence  of  retained  food  in  the 
stomach  or  of  a  dilated  stomach,  the  stomach  should  be 
emptied  at  once.  The  prompt  recognition  of  such  a  state 
and  its  relief  I  believe  will  save  many  lives.  With  adults 
when  in  doubt,  but  with  children  in  all  cases,  begin  treat- 
ment with  gastric  lavage. 

7.  Heart. — Sustain  the  circulation  with  the  help  of  digi- 
talis. CafYein  may  be  given  subcutaneously  or  as  black 
coffee  by  the  rectum. 

8.  Alkalis. — Avoid  alkalis.  If  such  have  been  previously 
given,  omit  at  the  rate  of  30  grams  a  day. 


CHAPTER   V. 

WEIGHT  PECULIARITIES. 

Most  diabetic  patients  are  obese  prior  to  the  onset  of 
diabetes.  As  soon,  however,  as  sugar  begins  to  be  lost  in  the 
urine,  the  weight  usually  falls  because  too  little  food  is  eaten 
to  make  up  for  that  lost.  It  is  not  uncommon  for  a  patient 
to  lose  50  pounds  before  treatment  begins,  and  occasionally 
a  patient  will  lose  as  much  as  100  pounds  during  the  course 
of  years.  A  diabetic  patient  in  reality  is  probably  in  safer 
condition  if  he  is  10  to  20  per  cent,  below  weight,  because 
thus  he  can  be  assured  that  he  is  not  overeating.  In  this 
respect  it  is  better  to  emulate  the  Indian  than  the  Eskimo. 
The  individual  10  per  cent,  and  even  20  per  cent,  below  weight 
may  not  be  a  delight  to  our  eyes,  but  if  over  thirty-five  years 
of  age  and  in  this  condition  he  is  much  more  acceptable  to 
the  Insurance  Company.  It  is  often  desirable  for  a  patient 
to  lose  weight,  but  this  should  be  undertaken  only  under 

Table  28. — The  Weight  of  Normal  Individuals.1 


Height. 

Age  15  to  24. 

Age  25  to  29. 

Age 

30  to  39. 

Age  40 

and  over. 

Ft. 

In. 

Cm. 

Lbs. 

Kg. 

Lbs. 

Kg. 

Lbs. 

Kg. 

Lbs. 

Kg. 

5 

0 

152.4 

120 

54.5 

125 

56.7 

129 

58.5 

133 

60.4 

5 

1 

154.9 

122 

55.4 

126 

57.2 

130 

59.0 

135 

61.3 

5 

2 

157.5 

124 

55.8 

128 

58.1 

132 

59.9 

138 

62.6 

5 

3 

160.0 

127 

57.6 

131 

59.5 

135 

61.3 

141 

64.0 

5 

4 

162.6 

131 

59.5 

135 

61.3 

139 

63.1 

144 

65.4 

5 

5 

165.1 

134 

60.8 

138 

62.6 

142 

64.4 

148 

67.2 

5 

6 

167.7 

138 

62.6 

142 

64.4 

146 

66.3 

152 

69.0 

5 

7 

170.2 

142 

64.4 

147 

66.7 

151 

68.5 

156 

70.8 

5 

8 

172.7 

146 

66.3 

151 

68.5 

155 

70.3 

161 

73.1 

5 

9 

175.3 

150 

68.1 

155 

70.3 

160 

72.8 

166 

75.3 

5 

10 

177.8 

154 

69.9 

159 

72.2 

165 

74.9 

171 

77.6 

5 

11 

180.3 

159 

72.2 

164 

74.4 

171 

77.6 

177 

80.3 

6 

0 

182.9 

165 

74.9 

170 

77.1 

177 

80.3 

183 

83.0 

6 

1 

185.4 

170 

77.1 

177 

80.3 

183 

83.0 

190 

86.2 

6 

2 

188.0 

176 

79.9 

184 

83.5 

190 

86.2 

196 

88.9 

6 

3 

190.5 

181 

82.1 

190 

86.2 

197 

89.4 

201 

91.2 

1  Average  for  men  and  women  with  clothes.  Clothes  weigh  8  to  10  pounds, 
or  about  4  kilograms. 


WEIGHT  PECULIARITIES 


107 


Table  29. — Heights  and  Weights  of  Children. 


Age. 


Height. 


Boys. 


Girls. 


Inches.      Cm.        Inches.      Cm. 


Weight. 


Boys. 


Pounds. 


Kg. 


Girls. 


Pounds.       Kg, 


Birth1 

1  year 

2  years 

3  years 

4  years 


20.6 
29.0 
32.5 
35.0 
38.0 


52.5 

73.8 
82.8 
89.1 
96.7 


20.5 
28.7 
32.5 
35.0 
38.0 


52.2 
73.2 

82.8 
89.1 
96.7 


7.55 
21.0 
27.0 
32.0 
36.0 


3.43 

9.54 

12.27 

14.55 

16.36 


7.16 
20.5 
26.0 
31.0 
35.0 


3.26 

9.31 

11.81 

14.09 

15.90 


The  heights  and  weights  in  the  above  table  are  net,  i.  e.,  without  shoes 
or  clothes. 


Age  at 

last 

birthday. 

5  years 

41.7 

105.9 

41.3 

104.9 

41.0 

18.6 

39.6 

18.0 

6  years 

43.9 

111.5 

43.3 

110.1 

45.2 

20.5 

43.4 

19.7 

7  years 

46.0 

116.8 

45.7 

116.0 

49.5 

22.5 

47.7 

21.7 

8  years 

48.8 

123.9 

47.7 

121.1 

54.5 

24.7 

52.5 

23.8 

'.)  years 

50.0 

127.0 

49.7 

126.2 

59.0 

27.0 

57.4 

26.0 

10  years 

51.9 

131.8 

51.7 

131.3 

65.4 

29.5 

62.9 

28.5 

11  years 

53.6 

136.1 

53.8 

136.6 

70.7 

32.1 

69.5 

31.5 

12  years 

55.4 

140.7 

56.1 

142.4 

76.9 

34.9 

78.7 

35.7 

13  years 

57.5 

146.0 

58.5 

148.5 

84.8 

38.5 

88.7 

40.3 

14  years 

60.0 

152.4 

60.4 

153.4 

95.2 

43.2 

98.3 

44.6 

15  years 

62.9 

159.7 

61.6 

156.4 

107.4 

48.8 

106.7 

48.5 

16  years 

64.9 

164.  S 

62.2 

157.9 

121.0 

55.0 

112.3 

51.0 

The  heights  in  the  above  table  are  without  shoes. 

The  weights  are  with  indoor  clothes.  These  make  up  for  boys  approxi- 
mately 8  per  cent.,  and  for  girls  7  per  cent.,  of  the  gross  weight. 

The  term,  "age  at  last  birthday,"  is  liable  to  give  a  wrong  impression, 
because  the  figures  given  are  really  average  figures  taken  from  all  the 
children  from  that  birthday  to  the  next,-_  A  more  accurate  term  is  the 
succeeding  half-year;  age  approximately  for  succeeding  half-year;  i.  e.,  five 
and  a  half  years  instead  of  five  years,  the  age  at  the  last  birthday. 

the  doctor's  direction.  Frequently  it  is  only  by  losing  weight 
that  a  patient  regains  the  power  to  tolerate  carbohydrate, 
but  as  yet  I  have  not  reached  the  point  of  purposely  beginning 
treatment  by  reducing  the  weight  of  a  diabetic  to  below 
normal,  though  perhaps  this  would  be  the  best  way.  As  a 
guide  to  the  proper  weight  for  a  diabetic,  the  average  weights 
of  individuals  for  given  heights  and  weights  when  dressed, 
according  to  Shepherd's  statistics,  are  given  in  Table  28. 
Along  with  these  I  include  weights  for  normal  children 
selected  by  Dr.  John  Lovett  Morse,  Table  29. 


108 


DETAILS  OF  DIABETIC  TREATMENT 


Changes  in  Weight  during  Treatment. — Diabetic  patients 
are  often  surprised  at  the  sudden  change  in  weight  which 
they  undergo  during  a  two  weeks'  course  of  treatment. 
Occasionally  the  weight  goes  up,  but  more  often  it  falls. 
It  may  remain  the  same  or  even  increase  during  several 
days  of  fasting.  The  reason  for  these  changes  is  to  be 
explained  by  the  retention  or  discharge  of  water  from  the 
tissues.  The  following  experiment  conducted  by  me  many 
years  ago  illustrates  this  well.  A  student  was  given  a  diet 
sufficient  to  maintain  his  body  weight  so  far  as  nutritive 
value  was  concerned,  but  from  his  food  salt  was  entirely 
removed.  As  a  result,  in  the  course  of  thirteen  days  the 
weight  fell  11.6(3  pounds.  Upon  the  resumption  of  his  former 
diet  with  salt  as  desired,  9  pounds  of  those  lost  were  regained 
in  three  days.  Diabetic  patients  often  gain  weight  from 
exactly  the  same  cause — namely,  the  ingestion  of  too  much 
salt.  Such  gain  in  weight,  however,  should  be  looked  upon 
at  its  real  value,  in  other  words,  simply  as  a  retention  of 
fluid  in  the  body. 

Case  No.  1378,  showing  considerable  dropsy,  lost  weight  as 
shown  in  Table  30.  When  the  equivalent  of  the  weight  lost 
was  weighed  out  in  water  it  half-filled  a  pail,  and  when  we 
realized  that  this  had  been  carried  about  all  day  in  the 
tissues  of  the  patient,  all  of  us  were  far  more  sympathetic 
toward  the  patient's  disinclination  to  go  up  and  down  stairs. 

Soon  after  entrance  the  salt  in  the  diet  was  partially 
restricted,  but  evidently  not  enough  to  prevent  increase  in 
weight,  as  the  chart  shows  (see  September  23-24).     From 


Table  30. — Chart  of  Case  No.  1378.    Illustration  of  Disappear- 
ance of  Dropsy  Coexistent  with  Loss  of  Weight 
Due  to  a   Salt-free  Diet. 


Urine. 

Diet  in  grams. 

Date, 
1917. 

Di- 
acetic 
acid. 

NaCl, 
grams. 

Sugar 
Total 
grams 

Carbo- 
hydrate 

Pro- 
tein. 

Fat. 

Alcohol. 

Calories. 

Weight, 
lbs. 

Sept.  13-14 

23-24 

Oct.    21-22 

0 
0 
0 

4.9 

0 
6 
0 

3 

17 

12 

20 
50 
53 

6 
42 

52 

50 
30 

146 
996 
938 

89 1 
98| 
691 

WEIGHT  PECULIARITIES  109 

this  point  onward  the  salt  was  excluded  with  the  greatest 
care  from  the  diet,  and  the  weight  uniformly  fell.  It  is  note- 
worthy that  this  patient  a  year  previously,  some  thousands 
of  miles  from  Boston,  had  been  given  during  a  period  of  six 
months  enemata  of  S  quarts  of  salt  and  soda  daily.  Further- 
more, she  was  then  in  the  habit  of  taking  beef  tea  loaded 
with  salt,  and  each  week  consumed  one  and  a  half  pounds 
of  salted  almonds,  as  well  as  using  salt  freely  in  her  food. 

It  is  also  interesting  that  although  the  carbohydrate  in 
an  individual's  diet  is  replaced  by  an  equivalent  number  of 
calories  in  the  form  of  fat,  the  weight  promptly  falls,  and  if 
the  reverse  procedure  is  adopted  the  weight  will  rise.  The 
loss  or  gain  of  weight  which  occurs  under  such  conditions 
may  amount  to  2  pounds  in  a  day  for  several  days.  Finally, 
there  is  a  real  reason  for  a  loss  of  weight  during  the  treat- 
ment of  diabetes,  due  to  the  fact  that  the  diet  is  often  defi- 
cient in  calories.    Against  this  loss  we  must  fight ! 


CHAPTER  VI. 

THE  DIET  OF  THE  UNTREATED  DIABETIC  IS 
EXPENSIVE. 

Case  No.  1171,  before  treatment  was  begun,  told  me  that 
he  ate  13  eggs  for  breakfast,  not  by  any  means  as  a  stunt, 
but  because  he  wanted  them.  Case  No.  1147,  a  lady  of 
thirty-five  years  of  age,  ate  a  dozen  eggs  a  day,  and  in 
response  to  my  request  gave  me  a  report  of  her  daily  diet 
before  she  began  treatment.  This  is  shown  in  Table  31.  It 
will  be  observed,  however,  that  the  carbohydrate  was  below 
normal — good  evidence,  therefore,  that  her  diet  had  already 
been  somewhat  altered  from  the  normal  before  the  time 
at  which  she  reported;  in  fact,  I  think  her  diet  was  origi- 
nally considerably  in  excess  of  that  recorded. 


Table  31. — Estimated  Diet  of  a  Woman  of  Thirty-five  Years, 
Case  No.  1147,  Prior  to  Treatment.     Weight  Seventy- 
two  Kilograms. 

Food  for  twenty-four  Carbohydrate,  Protein,  Fat, 

hours.  Quantity.  grams.  grams.  grams. 

Eggs 12  0  72  72 

Five  per  cent,  vegetables  450  grams.  15  8  0 

Milk 2000  c.c.  96  64  64 

Forty  per  cent,  cream    .  240  c.c.  8  8  96 

Butter 90  grams.  0  0  75 

Meat 120  grams.  0  32  20 

Bread 100  grams.  60  10  0 

Totals    .      .      179  194  327 

4  4  9 

Total  calories  716  776  2943 

Total  calories  4435  -f-  72  kilograms  =  approximately  60  calories  per 
kilogram  body  weight. 

Although  the  diet  contained  60  calories  per  kilogram  body 
weight  instead  of  the  normal  30  calories  the  patient,  while 


DIET  OF  UNTREATED  DIABETIC  IS  EXPENSIVE      111 

upon  it,  lost  66  pounds  in  a  little  over  two  and  a  half  years. 
The  reason  for  this  was  apparent,  for  on  October  G,  1916, 
the  volume  of  the  urine  was  estimated  at  6000  c.c.  (6  quarts) 
and  the  sugar  was  found  to  be  5  per  cent,  or  300  grams 


Fig.  14. — The  quantity  of  sugar  daily  lost  in  the  urine  by  a  moderate 
diabetic,  Case  No.  1147.     (See  also  frontispiece) 

(10  ounces),  the  equivalent  of  a  loss  of  1200  calories  in  the 
urine  in  twenty-four  hours.  In  one  year  this  would  amount 
to  240  pounds  of  sugar!  After  a  two  weeks'  stay  in  the  hos- 
pital she  felt  more  content  with  a  diet  of  1600  calories — a 
trifle  less  than  her  body  needs — than  when  upon  that  at 
entrance. 


Fig.  15. — The  quantity  of  sugar  daily  lost  in  the  urine  by  a  severe 
diabetic,  Case  No.  295.     (See  also  frontispiece.) 

It  is  obvious  that  the  saving  of  food  which  results  from 
becoming  sugar-free  under  modern  treatment  must  be  con- 
siderable. It  is  the  diet  of  the  untreated  diabetic  which  is 
expensive,  since  the  large  excess  is  far  worse  than  wasted. 


112  DETAILS  OF  DIABETIC  TREATMENT 

Case  No.  295  voided  in  twenty-four  hours  on  October 
23-24,  1909,  approximately  10  liters  of  urine  (nearly  20 
pounds)  containing  680  grams  of  sugar,  the  equivalent  of 
2720  calories!  The  weight  of  this  patient  was  50  kilos.  In 
other  words,  he  lost  in  the  urine  54  calories  per  kilo,  an 
amount  sufficient  in  calories  to  supply  almost  double  his 
own  needs  if  taken  in  the  form  of  food  which  he  could 
assimilate. 

Diabetic  patients  with  acid  poisoning  lose  calories  in  the 
urine  not  only  in  the  form  of  sugar  but  as  acid  bodies  as  well. 
The  quantity  of  acid  bodies  thus  lost  is  quite  considerable. 
These  acid  bodies  represent  wasted  food  just  as  much  as 
does  the  sugar  in  the  urine.  Case  No.  344  is  a  good  illustra- 
tion of  this.  On  December  25-26,  1911,  he  excreted  188 
grams  sugar,  the  equivalent  of  (188  X  4)  752  calories,  and 
in  addition  55  grams  acid  bodies,  equivalent  to  (55  X  5) 
275  calories.  Acid  intoxication  is  really  a  dreadful  robber, 
for  besides  stealing  the  food  of  a  patient,  it  frequently  steals 
his  life! 


CHAPTER  VII. 
CARE  OF  THE  TEETH. 

Many  diabetics  have  sound  teeth,  thus  showing  that 
diabetes  is  not  necessarily  productive  of  bad  teeth.  On  the 
other  hand,  the  teeth  should  always  be  kept  in  good  condi- 
tion, for  it  is  common  to  have  the  diabetes  grow  worse  in  the 
presence  of  inflammatory  conditions  about  the  teeth  and 
gums.  The  teeth  should  be  cleaned  after  each  meal  and  it 
is  desirable  to  have  them  cleaned  by  a  dentist  at  least  every 
three  months.  If  the  teeth  are  to  be  extracted,  novocain 
injected  cautiously  acts  admirably.  If  necessary,  gas  or 
gas  and  oxygen  may  be  employed,  but  ether  should  be  used 
only  when  the  carbohydrate  tolerance  is  high  and  after  careful 
consideration. 

I  consider  the  care  of  the  teeth  of  enough  importance  to 
insert  the  following  abstract  of  a  dentist's  leaflet,  which 
supplies  specific  instruction  on  this  subject. 

Clean  Teeth  Will  Not  Decay. 

How  can  all  the  food  be  removed  from  all  the  surfaces  of 
all  the  teeth  after  each  meal? 

1.  By  brushing. 

2.  By  using  floss  silk  between  the  teeth. 

3.  By  thoroughly  rinsing  the  mouth  with  lime  water. 
Rides  for  Brushing  the  Teeth. — 1.  Brush  four  times  a  day: 

Before  breakfast,  with  clear  water. 

After  each  meal,  with  a  tooth  paste  or  powder. 

The  teeth  must  be  clean  and  free  from  food  before 

going  to  bed,  as  most  of  the  decay  takes  place  while 

sleeping. 
2.  Brush  two  minutes   each   time  (two  minutes  by'  the 

clock). 


114  DETAILS  OF  DIABETIC  TREATMENT 

It  takes  two  minutes  of  brushing  to  properly  stimulate 
the  gums  and  thoroughly  cleanse  the  teeth.  Be  sure 
and  brush  the  gums. 

3.  Do  not  use  pressure  with    the  brush.     A  fast,  light 

stroke  is  the  best.     A  brush  should  never  be  worn 
out  by  having  its  bristles  flattened  and  spread  out. 

4.  Candies,  sugar,  crackers,  cake,  pastries,  bread  will  all 

decay  the  teeth  if  allowed  to  remain  on  their  surfaces. 

Floss  Silk. — Four-fifths  of  the  decay  of  teeth  takes  place 
on  the  surfaces  between  the  teeth  and  one-fifth  on  the  sur- 
faces on  which  one  chews.  There  is  but  one  way  which  is 
effective  in  removing  the  food  from  between  the  teeth,  and 
that  is  with  a  piece  of  floss  silk. 

Use  a  section  of  floss  about  twelve  inches  long.  Hold 
one  end  between  the  thumb  and  first  finger  of  the  left  hand 
and  wrap  the  floss  twice  around  the  end  of  the  first  finger. 
Do  the  same  with  the  thumb  and  first  finger  of  the  right 
hand.  Now  by  using  combinations  of  the  ends  of  the  thumbs 
and  second  fingers  the  floss  may  be  carried  into  the  mouth 
and  forced  carefully  between  all  the  teeth.  Rub  it  back  and 
forth  against  the  surfaces  of  each  tooth  to  loosen  and  remove 
the  food  and  to  clean  these  surfaces.  After  a  little  practice 
one  can  floss  all  the  surfaces  between  the  teeth  in  a  minute's 
time. 

There  still  remains  on  the  surfaces  of  the  teeth,  especially 
between  them,  a  glue-like  deposit  known  as  mucin.  This 
mucin  must  be  removed,  as  it  allows  the  bacteria  to  cling  to 
these  surfaces.  The  most  effective  and  harmless  solvent 
to  use  as  a  mouth  wash  is  lime  water.  In  fact  if  but  one 
thing  could  be  used  to  prevent  decay  of  the  teeth,  lime  water 
used  three  times  daily  would  prove  to  be  the  most  valuable. 

Preparation  of  Lime  Water. — Secure  coarse,  unslaked  lime 
and  crush  it  into  a  fine  powder.  Place  a  half-cupful  in  an 
empty  quart  bottle  and  fill  nearly  full  with  cold  water. 
Thoroughly  shake  and  then  allow  the  lime  to  settle  to  the 
bottom  of  the  bottle,  which  will  take  several  hours.  Avoid 
injury  to  furniture  from  heat  generated  in  the  bottle.  After 
the  lime  has  settled  pour  off  as  much  of  the  clear  water  as 
possible  without  losing  any  of  the  lime,  as  this  first  mixing 


CARE  OF  THE  TEETH  115 

contains  the  washing  of  the  lime.  Again  fill  with  cold  water, 
shake  well  and  allow  it  again  to  settle. 

Into  an  empty  twelve-ounce  bottle  pour  the  clear  lime 
water,  taking  care  not  to  stir  up  the  lime  in  the  bottom  of  the 
bottle.  Again  fill  the  quart  bottle  with  cold  water,  shake 
thoroughly  and  set  it  aside  to  use  when  the  smaller  bottle 
becomes  empty.  This  process  may  be  repeated  until  the 
half-cup  of  lime  has  made  five  or  six  quarts  of  mouth  wash. 

The  twelve-ounce  bottle  is  used  as  it  is  more  easily  handled 
at  the  wash  bowl.  After  brushing  and  flossing  the  teeth, 
pour  out  a  little  of  the  lime  water  in  a  glass  and  taking  it  in 
the  mouth  force  it  back  and  forth  between  the  teeth  with 
the  tongue  and  cheeks  until  it  foams.  If  you  rinse  it  long 
enough  to  make  it  foam  it  has  then  been  in  the  mouth 
long  enough  to  have  a  beneficial  action  on  the  teeth.  After 
spitting  it  out  rinse  the  mouth  with  clear  water  to  take  away 
the  taste  of  the  lime.  If  the  lime  water  is  a  little  strong  at 
first,  dilute  it  with  clear  water  in  the  small  bottle,  half  and 
half.  It  should  be  used  clear  and  full  strength  as  soon  as  the 
gums  become  hard  and  healthy  from  brushing. 


CHAPTER  VIII. 
CARE  OF  THE  SKIN. 

The  skin  must  be  kept  unusually  clean.  Take  a  tub  bath 
daily,  but  avoid  prolonged  cold  baths.  Short  cold  baths  are 
often  desirable.  One  boy  I  know  took  his  cold  morning  bath 
in  four  seconds ;  adults  often  go  to  the  other  extreme  in  point 
of  time  and  thus  lose  the  good  effect. 

Protect  the  Skin  from  Injuries. — If  any  infection  occurs, 
see  a  physician  at  once.  Infections  of  the  skin  are  apparently 
less  common  now  than  formerly  and  this  may  be  attributed 
to  cleanliness.  Such  infections  are  and  should  be  rare  in 
diabetic  patients  under  treatment.  They  demand  immediate, 
thorough,  yet  gentle,  treatment.  One  of  the  first  duties  of 
the  physician  is  to  tell  diabetic  patients  to  keep  the  skin 
clean  and  to  report  the  beginning  of  an  infection  at  once. 
Patients  should  be  warned  of  the  danger  from  slight  wounds, 
should  specifically  be  advised  not  to  allow  manicurists  or 
chiropodists  to  draw  a  drop  of  blood,  and  cautioned  to 
promptly  report  any  injury  to  the  skin.  Absolute  cleanliness 
of  the  body  is  essential.  Subcutaneous  injections,  whether 
of  water,  salt  solution  or  drugs  may  be  harmful,  but  with 
modern  asepsis  I  hope  can  be  safely  employed.  It  is  common 
for  salt  solution  or  solutions  of  sodium  bicarbonate,  when 
injected  subpectorally,  to  result  in  abscess.  If  there  is  the 
slightest  tendency  to  furunculosis,  I  at  once  adopt  simple 
measures  analogous  to  those  described  by  Bowen.1  The 
patient  is  advised  to  wash  the  whole  body  twice  a  day  with 
soap  and  water,  using  a  wash  cloth  or  piece  of  flannel,  and 
to  dry  the  skin  without  rubbing,  so  as  to  avoid  breaking  open 
any  pustule;  the  whole  body  is  then  bathed  with  a  saturated 
solution  of  boracic  acid  in  water,  with  the  addition  of  a  small 

1  Bowen:  Jour.  Am.  Med.  Assn. ,,1910,  lv,  p.  209;  Boston  Med.  and  Surg. 
Jour.,  1917,  clxxvi,  p.  96. 


CARE  OF  THE  SKIN  117 

proportion  camphor  water  and  glycerin.  I  have  often  used  a 
solution  of  two  parts  alcohol  and  one  part  water  to  advantage, 
but  I  notice  that  Bowen  in  his  second  paper  still  prefers  the 
boracic  acid.  Individual  furuncles  may  be  treated  with  the 
following  ointment;  according  to  Bowen: 

Boracic  acid 4 

Precipitated  sulphur 4 

Carbolated  petrolatum 30 

One  should  be  careful,  however,  not  to  overtreat  the  skin. 
Harm  may  result  from  frequent  dressings.  The  simplest 
lotions  should  always  be  employed.  In  severe  cases  the 
patient  should  be  put  to  bed,  all  linen  changed  twice  daily, 
and  the  patient  treated  in  as  aseptic  a  way  as  possible.  In 
a  few  cases  vaccines  have  appeared  to  be  of  marked  benefit. 
"This  procedure,  thorough  bathing  and  soaping,  the  applica- 
tion of  the  borated  solution,  and  the  dressing  of  the  individual 
furuncles,  is  repeated,  as  has  been  said,  morning  and  night. 
A  further  point  of  vital  importance  relates  to  the  clothing 
that  is  worn  next  the  skin.  Every  stitch  of  linen  worn  next 
"to  the  skin  should  be  changed  daily,  and  in  the  case  of 
extensive  furunculosis  all  the  bedclothing  that  touches  the 
individual,  as  well  as  the  nightclothing,  should  be  subjected 
to  a  daily  change.  Naturally,  this  treatment  must  be  con- 
tinued for  several  weeks  after  the  last  evidence  of  pyogenic 
infection  has  appeared,  and  this  fact  must  be  emphasized 
to  the  patient  at  the  outset."     (Bowen.) 


CHAPTER   IX. 
TREATMENT  OF  CONSTIPATION. 

The  bowels  should  move  daily.  The  coarse  vegetables 
and  fruit  of  the  diet  may  prove  quite  sufficient,  but  if  neces- 
sary, bran  muffins  made  with  agar  agar  (see  page  130)  may 
be  employed.  Never  purge  the  bowels  but  depend  upon  an 
enema  or  upon  simple  laxatives,  such  as  aloin,  grain  \;  fluid- 
extract  of  cascara  sagrada,  10  to  30  drops;  extract  cascara 
sagrada,  5  grains,  or  compound  rhubarb  pills. 

If  diarrhea  occurs,  go  to  bed,  keep  warm  and  drink  hot 
water. 

If  the  patient  has  not  had  a  movement  for  several  days, 
at  the  beginning  of  treatment  give  an  enema  followed  by 
some  simple  cathartic  or  mild  aperient,  and  another  enema 
twelve  to  twenty-four  hours  later;  but  do  not  purge  the 
patient.  Gain  enough  is  obtained  if  a  movement  is  produced 
once  in  twenty-four  hours  when  it  has  only  been  taking  place 
once  in  seventy-two.  In  other  words,  do  not  upset  any  patient 
who  is  in  a  tolerable  state. 

The  following  exercises  for  constipation  were  recommended 
to  me  by  Mr.  Gustaf  Sundelius: 

Home  Exercises  for  Constipation. 

1.  Abdominal  Kneading  and  Stroking. — Kneading. — Lying 
down,  with  knees  slightly  drawn  up.  Place  hands  one  on 
top  of  the  other  on  the  abdomen  at  the  right  groin;  with 
small  circular  movements  and  deep  pressure  work  upward 
until  the  ribs  are  met,  then  across  toward  left,  following  the 
boundary-line  of  the  chest,  then  downward  to  the  left  groin. 
Repeat  twenty  to  fifty  times.  Stroking.  With  hands  simi- 
larly placed,  make  lorig,  steady  and  deep  strokes  following 
the  same  route.    Repeat  twenty-five  to  one  hundred  times. 


TREATMENT  OF  CONSTIPATION  119 

2.  Leg-rolling. — Lying  down,  take  hold  of  both  legs  just 
below  the  knees,  press  the  knees  up  close  to  the  abdomen, 
then  carry  them  apart,  then  down  and  inward  until  they 
meet  again,  thus  letting  the  knees  describe  two  circles. 
Repeat  ten  to  twenty  times. 

3.  Abdominal  Compression. — Standing  against  the  wall 
with  hands  clasped  behind  neck,  draw  the  abdomen  forcibly 
in,  using  the  abdominal  muscles,  hold  a  second,  then  let  go. 
Repeat  ten  to  forty  times. 

4.  Trunk-rolling. — Standing  with  hands  on  hips,  feet 
apart  and  legs  well  stretched,  roll  the  upper  body  in  a  circle 
on  the  hips  by  bending  forward,  to  the  left,  backward  and 
to  the  right.  Then  reverse,  and  repeat  six  to  twelve  times 
each  way. 

Case  No.  559  warded  off  constipation  by  sawing  wood, 
and  Case  No.  265  regulated  his  bowels  by  eating  a  slice  of 
raw  cabbage  for  breakfast. 


CHAPTER  X. 
DRUGS  IN  THE  TREATMENT  OF  DIABETES. 

Drugs  are  not  recommended  by  physicians  like  Professor 
Naunyn,  the  Nestor  of  diabetic  treatment,  or  by  those 
concerned  in  the  recent  advance  in  diabetic  treatment  in 
this  country. 

Drugs  are  not  prescribed  with  the  purpose  of  lowering  the 
sugar  in  the  urine  in  the  most  famous  of  our  large  hospitals. 

On  the  other  hand,  drugs  are  frequently  recommended, 
I  have  observed,  (1)  by  physicians  who  do  not  determine 
the  quantity  of  carbohydrate  in  their  patients'  diets  or  the 
quantity  of  sugar  in  the  urine,  (2)  by  those  who  are  not  con- 
nected with  large  hospitals,  and  (3)  by  those  who  do  not  have 
access  to  well-equipped  laboratories. 

I  wish  I  knew  of  a  good  drug  for.  diabetic  patients.  It 
would  save  me  so  much  time  and  talk. 


PART   III. 
THE  DIABETIC  MENU  AND  FOOD  VALUES. 


CHAPTER   I. 
DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS. 

The  narrow  confines  of  the  diabetic  diet  have  greatly 
stimulated  the  manufacture  of  so-called  diabetic  foods. 
These  are  often  serviceable,  but  are  to  be  employed  with 
discretion.  Their  use  should  be  discouraged  at  the  beginning 
of  treatment.  The  patient  should  never  become  dependent 
upon  special  diabetic  foods,  for  they  are  often  unobtainable, 
always  make  him  conspicuous,  and  when  he  acquires  a 
disgust  for  foods  of  this  class  it  is  all  the  harder  to  abide  by 
the  original  diet.  When  the  patient  buys  one  of  these  foods, 
unfortunately  he  is  often  given  a  list  of  other  diabetic  foods 
and  a  new  diabetic  diet  list,  and  confusion  in  the  diet  often 
results.  The  patients  under  my  care  who  have  done  best 
either  never  use  special  diabetic  floods  or  only  a  few  varieties, 
such  as  Akoll  Biscuits,  Barker's  Gluten  Flour,  Casoid  Flour, 
Hepco  Flour,  Lister  Flour,  No.  1  Proto  Puffs  and  Sugar-free 
Milk. 

Substitutes  for  Bread. — Many  of  the  preparations  upon  the 
market  contain  as  great  or  even  a  greater  quantity  of  car- 
bohydrate than  ordinary  bread;  a  few  contain  less;  but  the 
percentage  of  carbohydrate  may  vary  from  time  to  time. 
Patients,  and  sometimes  physicians,  forget  that  substitutes 
for  bread  must  be  prescribed  only  in  definite  amounts.  A 
diabetic  bread  should  never  be  prescribed  without  a  knowl- 
edge of  its  content  of  carbohydrate,  protein  and  fat. 


122  DIABETIC  MENU  AND  FOOD  VALUES 

The  bread  of  one  of  the  largest  bakeries  in  Boston,  upon 
analysis,  showed  55  per  cent,  carbohydrate.  Bread  made 
without  milk  or  sugar,  but  with  water  and  butter,  con- 
tains 45  to  50  per  cent,  carbohydrate.  Such  a  bread  is 
undoubtedly  superior  to  many  different  bread  substitutes 
upon  the  market.  The  percentage  of  carbohydrate  in  toast 
is  greater  than  in  plain  bread  because  it  contains  less  water. 
Some  of  the  coarser  kinds  of  bread,  such  as  rye  bread,  graham 
bread,  black  bread  and  pumpernickel,  contain  somewhat  less 
carbohydrate.  Never  give  bread  substitutes  early  in  treat- 
ment.   Teach  patients  to  live  without  them. 

Bran  Bread. — Bran  is  being  more  and  more  employed  in 
the  diet  of  diabetic  patients.  This  is  neither  more  nor  less 
than  the  use  of  cellulose,  and  this  is  supposed  to  have  no 
effect  upon  the  metabolism.  Unfortunately,  the  availability 
of  the  protein,  fat  and  carbohydrate  of  wheat  bran  to  the 
diabetic  patient  has  not  been  determined,  although  there  are 
plenty  of  data  upon  its  digestibility  by  ruminant  animals. 
Bread  made  of  bran  alone  is  not  very  palatable,  though  with 
the  fat  of  bacon  or  butter  it  is  liked  better.  It  furnishes 
bulk  and  acts  favorably  upon  constipation.  If  made  with 
eggs  and  butter  the  flavor  is  improved.  It  should  be 
remembered  that  bran  often  contains  a  considerable  quantity 
of  starch.  For  this  reason  bran  biscuits  often  prove  to  be  a 
delusion  and  a  snare,  and  I  dread  to  see  them  on  a  patient's 
tray.  In  large  hospitals  where  diabetic  patients  are  con- 
stantly being  treated  the  danger  is  less,  for  the  bran  is  bought 
by  the  same  person  and  at  the  same  place;  but  in  private 
practice  this  is  different.  In  purchasing  bran  go  to  a  feed 
store  and  ask  for  coarse  bran  for  cattle  and  not  for  bran  for  the 
table.  The  various  preparations  of  bran,  bran  breads  and 
cookies  sold  under  trade  names  often  contain  carbohydrate 
other  than  bran,  hence  the  reason  for  their  palatable  taste; 
beware  of  them!  They  may  contain  over  60  per  cent, 
carbohydrate,  of  which  less  than  10  per  cent,  is  real  bran. 
Mild  diabetics  get  into  little  trouble  with  bran,  but  the 
serious  ones  often  suffer.  The  starch  may  be  washed  out 
with  water  by  tying  the  bran  in  a  cheesecloth  and  fastening 
the  same  on  a  faucet.     It  should  be  thoroughly  mixed  and 


DIETETIC  SUGGESTIONS,   RECIPES  AND  MENUS     123 

kneaded  from  time  to  time  to  be  sure  the  water  reaches  all 
portions,  and  should  be  washed  until  the  water  comes  away 
clear.     This  may  require  an  hour.1 

Gluten  Breads. — These  breads  are  made  by  removing  the 
sugar-forming  material  from  the  flour.  It  is  surprising  how 
thoroughly  this  can  be  done.  I  have  often  found  the  per- 
centage of  carbohydrate  in  one  such  flour  to  be  negligible. 
The  large  quantity  of  protein  in  small  bulk  which  they  con- 
tain is  objectionable. 

Light  Breads. — French  bread  cut  in  thin  slices  is  often 
useful,  because  it  is  bulky,  gives  the  appearance  of  a  large 
quantity  and  carries  much  butter.  Manufacturers  have 
taken  advantage  of  this  idea,  and  many  light  breads  are  on 
the  market.  These  breads  often  contain  about  the  same 
quantity  of  carbohydrate  as  ordinary  bread,  though  a  few 
contain  considerably  less.  Their  virtue  often  consists  solely 
in  their  bulk,  which  allows  a  surface  on  which  to  spread 
butter.  I  seldom  advise  breads.  It  is  better  for  the  patient 
to  forget  the  taste. 

Various  other  substances  have  been  used  for  flour  in  the 
manufacture  of  bread.  Thus,  aleuronat  meal  has  been 
employed,  and  with  it  have  been  mixed  various  vegetable 
products.  A  group  of  casein  breads  is  upon  the  market  in 
the  form  of  casoid  flour  and  Lister's  Diabetic  Flour,  and  to 
some  diabetics  these  are  valuable. 

Soy  bean  is  also  extensively  used,  and  probably  deserves  a 
still  wider  introduction  into  the  diabetic  diet.  The  carbo- 
hydrate in  it  is  unassimilable.  It_is  used  in  the  manufacture 
of  Hepco  Flour.  Agar  agar  may  be  used  to  dilute  the  flour 
or  to  add  to  bran  and  also  to  relieve  the  constipation  of  the 
diabetic,  which  is  frequently  troublesome. 

Substitutes  for  Milk. — A  few  tablespoonfuls  of  cream  are  a 
great  comfort  to  a  diabetic  patient.  Except  in  cases  with  a 
very  low  tolerance  a  gill  (120  c.c.)  of  20  per  cent,  cream  can 

1  Four  preliminary  analyses  of  washed  bran  showed  the  following  per- 
centages of  starch:  0.6,  1.8,  2.7,  5.2  per  cent.  Two  preliminary  analyses 
showed  pentosan  29.8,  33.5.  The  wide  variations  in  the  percentages  of 
starch  will  account  for  the  occasional  occurrence  of  sugar  in  the  urine  fol- 
lowing the  use  of  bran  cakes.  I  hope  these  investigations  will  be  continued 
in  the  laboratory  from  which  I  obtained  these  analyses. 


124  DIABETIC  MENU  AND  FOOD  VALUES 

generally  be  allowed,  and  if  it  is  desirable  to  give  more  fat 
without  increasing  carbohydrate  and  protein,  a  gill  of  40 
per  cent,  cream  is  also  well  borne.  Formerly  patients  took 
half  a  pint  of  40  per  cent,  cream  readily.  With  severe  cases 
it  is  seldom  possible  to  allow  more  than  GO  to  90  c.c.  of  20 
per  cent,  cream,  for  the  balance  of  the  fat  which  can  be 
safely  employed  can  more  advantageously  be  taken  in  meat, 
butter,  oil  and  cheese.  On  the  other  hand,  fat  having  been 
removed,  the  chief  value  of  the  milk  to  the  diabetic  patient 
is  lost.  The  percentage  of  sugar  in  sour  milk  is  not  much 
less  than  in  fresh  milk.  Recently,  sugar-free  milks1  have 
been  put  upon  the  market  on  a  large  scale,  and  many  of  my 
patients,  particularly  children,  have  found  them  of  distinct 
advantage.  These  preparations  of  diabetic  milk  will  keep 
from  one  to  three  weeks,  and  are  consequently  of  great 
value  to  patients  when  travelling.  As  a  rule  they  are  con- 
centrated one-half.  Consequently  they  should  be  diluted 
before  being  used.  They  are  so  valuable  for  diabetic  patients 
that  I  always  encourage  their  use  in  small  quantities  at  first, 
so  that  the  patient  can  become  accustomed  to  the  artificial 
taste  and  can  determine  the  form  in  which  the  milk  is  most 
agreeable  to  him.  This  is  often  as  equal  parts  of  milk  and 
Vichy  Celestins. 

Williamson2  suggested  the  following  rule  for  the  manu- 
facture of  artificial  milk:  "To  about  a  pint  of  water,  placed 
in  a  large  drinking  pot  or  tall  vessel,  three  or  four  tablespoon- 
fuls  of  fresh  cream  are  added  and  well  mixed.  The  mixture 
is  allowed  to  stand  from  twelve  to  twenty-four  hours,  when 
most  of  the  fatty  matter  of  the  cream  floats  to  the  top;  it 
can  be  skimmed  off  with  a  teaspoon  easily,  and  upon  examina- 
tion it  will  be  found  practically  free  from  sugar.  This  fatty 
matter  thus  separated  is  placed  in  a  glass."  The  white  of  an 
egg  is  added  to  it  and  the  mixture  well  stirred.  Then  dilute 
with  water  until  a  liquid  is  obtained  which  has  the  exact 
color  and  consistency  of  ordinary  milk.  "  If  a  little  salt  and  a 
trace  of  saccharin  be  added,  a  palatable  drink,  practically 

1  D.  Whiting  &  Sons,  Boston. 

2  Williamson:  Diabetes  Mellitus  and  its  Treatment,  Macmillan  Company, 
1898,  p.  334. 


DIETETIC  SUGGESTIONS,   RECIPES  AND  MENUS     125 

free  from  milk-sugar,  is  produced,  which  has  almost  the  same 
taste  as  milk,  and  which  contains  a  large  amount  of  fatty 
material.  With  very  little  practice  the  right  proportions 
can  be  easily  guessed,  and  of  course  much  larger  quantities 
can  be  employed  (in  order  to  prepare  a  considerable  amount 
of  the  drink  at  one  time)  than  those  mentioned  above." 

Rennet  may  be  made  from  milk,  but  unless  the  curd  is 
carefully  washed  it  will  contain  2  to  2.5  per  cent,  lactose. 
When  the  rennet  is  made  from  cream  the  lactose  is  materially 
diminished.  Kefir  contains  approximately  2.4  per  cent, 
milk-sugar.  Yon  Xoorden  says  this  milk  has  also  been  of 
great  help  in  the  treatment  of  diabetes  in  children. 

Lawrence  Litchfield,  of  Pittsburgh,  gives  whipped  cream 
to  his  patients  made  according  to  the  following  rule:  Add 
two  ounces  of  40  per  cent,  cream  to  a  pint  of  cold  water  in 
a  Mason  jar  and  hav"  it  shaken  vigorously  until  the  cream 
is  thoroughly  "whipped."  Sometimes  a  trace  of  saccharin 
is  added,  usually  not.  "My  patients  like  to  eat  this  with 
a  spoon,  but,  of  course,  it  can  be  used  in  any  way  that  is 
desired.    It  contains  only  a  trace  of  sugar." 

The  fermented  milks  contain  about  half  as  much  carbo- 
hydrate as  ordinary  milk. 

RECIPES. 

Many  books  have  been  written  containing  recipes  for  dia- 
betic patients.  With  modern  methods  of  treatment,  however, 
most  of  these  rules  are  worthless  _for  severe  diabetic  patients 
because  of  their  high  content  of  protein  and  fat.  In  general 
such  patients  prefer  and  should  be  encouraged  to  take  simple 
natural  foods  rather  than  artificial  ones. 

The  mild  cases  of  diabetes  need  no  special  recipes.  Des- 
serts can  often  be  made  with  gelatin,  and  this  may  be  flavored 
with  coffee,  lemon,  rhubarb  or  cracked  cocoa.  In  preparing 
such  desserts  if  saccharin  is  used  it  should  be  added  as  late 
as  possible  during  the  cooking,  for  it  is  apt  to  become  bitter 
with  heat.  It  is  always  a  safe  rule  to  add  too  little  rather 
than  too  much  saccharin.  Usually  one  need  pay  little 
attention  to  the  quantity  of  protein  in  the  gelatin,  because 


126  DIABETIC  MENU  AND  FOOD  VALUES 

the  ordinary  portion  of  jelly  contains  only  about  2.5  grams. 
One  of  my  patients  on  a  very  rigid  diet  so  enjoyed  the  bulk 
of  the  gelatin  as  to  take  10  grams  daily.  She  accomplished 
this  by  having  the  gelatin  made  very  thick. 

DIABETIC  BREAD. 

1  Box  Lister's  Diabetic  Flour1 
3  Eggs 

Method. — Separate  whites  and  yokes  of  eggs.  Add  to 
whites  salt  to  taste.  Beat  whites  until  very  thick.  Beat 
yolks  until  thick  and  lemon  colored.  Combine  and  beat 
with  egg-beater.  Fold  in  gradually  one  box  of  Lister's 
Diabetic  Flour.  Bake  in  tin  5  inches  long,  3  inches  wide 
and  3  inches  high  (straight  sides).  Have  oven  hot.  If  baked 
in  gas-stove  oven,  bake  for  fifteen  mnutes,  full  heat,  then 
reduce  heat  one-half  for  ten  minutes  longer.  If  baked  in 
coal  or  wood  oven,  bake  from  fifteen  to  thirty  minutes.  Do 
not  open  oven  door  until  bread  is  done.  Do  not  remove 
from  tin  until  partly  cooled.  Each  loaf  contains  protein,  58 
grams;  fat,  18.6  grams;  calories,  397. 

LISTER'S  LITTLE  CAKES. 

lr.  ^  }  Makes  150  Cakes 

10  Eggs  J 

Each  cake  contains  protein,  0.66  gram;  fat,  0.40  gram; 
calories,  6. 

1  The  following  analysis  of  Lister's  Diabetic  Flour  is  given  out  by  the 
manufacturers.  This  is  used  in  the  preparations  of  a  number  of  the 
recipes  which  follow: 

ANALYSIS   OF    LISTER'S   DIABETIC    FLOUR. 

Grams  in  each 
Per  cent.  2-ounce  box. 

Moisture 10.66  6.05 

Ash 1.63  0.93 

Fat 0.67  0.38 

Protein 69.95  39.66 

Starch 0.00  0.00 

Sugar 0.00  0.00 

Leavening 17.09  9.69 


DIETETIC  SUGGESTIONS,   RECIPES  AND  MENUS     127 

Method. — Beat  eggs  until  very  stiff.  Stir  in  one  box  of 
Lister's  Diabetic  Flour  without  further  beating.  Use  flat 
baking  pan  that  has  been  slightly  greased,  deposit  the  dough 
or  batter  in  small  amounts  about  the  size  of  a  50-cent  piece. 
Bake  in  moderately  hot  oven  for  about  ten  minutes. 

DIABETIC  NOODLES. 

Method. — To  the  well-beaten  yolks  of  two  eggs,  add  two 
tablespoonfuls  of  warm  water  and  a  little  salt.  Slowly 
stir  in  one  box  of  Lister's  Diabetic  Flour.  Knead  and  roll 
on  pie-board.  When  almost  dry,  roll  and  cut  fine.  Dry 
thoroughly. 

DIABETIC  MUFFINS. 

1  Box  Lister's  Diabetic  Flour 

1  Egg 

3  Tablespoonfuls  of  sweet  heavy  cream  (40  per  cent,  cream) 

2  Tablespoonfuls  of  bacon  fat 

Same  quantity  of  butter,  melted  lard  or  Crisco  may  be  used 
in  place  of  bacon  fat.  This  will  make  eight  muffins,  each 
muffin  having  food  value  equivalent  to  one  egg  (or  protein, 
6  grams;  fat,  6  grams;  calories,  78). 

Method. — Beat  white  of  egg  very  stiff;  beat  yolk 
separately  from  white;  to  the  beaten  yolk  add  the  cream 
and  beat;  then  add  bacon  fat  (butter,  melted  lard,  or  melted 
Crisco);  beat  again,  then  add  the  beaten  white  of  egg;  lastly 
the  flour,  beating  the  mixture  all  the  while  the  flour  is  slowly 
added.  Put  in  buttered,  hot  muffin  irons  and  bake  for  ten 
to  twenty  minutes.  If  coal  range- is  used,  bake  for  fifteen 
minutes  and  have  the  oven  hot.  Oven  door  should  not  be 
opened  for  ten  minutes.  Use  old-fashioned  cast-iron  muffin 
iron. 

LISTER'S  FLOUR  AND  BRAN  MUFFINS  USEFUL  IN 
DIABETIC  CONSTIPATION. 

1  Level  tablespoonful  lard,  bacon  fat,  butter  or  crisco 

1  Egg 

2  Tablespoonfuls  heavy  cream 
1  Cupful  washed  bran 

1  Package  Lister's  Flour 
\  Cupful  water  or  less 


128  DIABETIC  MENU  AND  FOOD  VALUES 

Tie  dry  bran  in  cheesecloth  and  soak  one  hour.  Wash  by 
squeezing  water  through  and  through.  Change  water  sev- 
eral times;  wring  dry.  Separate  egg  and  beat  thoroughly. 
Add  to  the  egg  yolk  the  melted  lard,  cream  and  beaten  egg 
white.  Add  Lister's  Flour,  washed  bran  and  water.  Make 
nine  muffins. 

DIABETIC  COOKIES. 


1  Box  Lister's  Diabetic  Flour 

1  Egg 

3  Tablespoonfuls  of  cream 

3  Tablespoonfuls  of  butter  or  bacon  fat 


Method. — Beat  egg  until  light.  Add  cream  and  beat 
again.  Add  butter  and  beat  again.  Then  add  Lister's 
Flour  slowly.  A  little  caraway  seed,  ginger  or  vanilla  may 
be  added  to  suit  the  taste.  Roll  very  thin  and  only  a  small 
amount  at  a  time.    Bake  in  hot  oven  about  ten  minutes. 

Makes  thirty  cookies  of  about  23  calories  each. 


DIABETIC  BISCUITS. 

1   Box  Lister's  Diabetic  Flourl  ^  . 

3  Eggs  J 

Each  biscuit  contains  protein,  9.70  grams;  fat,  3.05  grams; 
calories,  60. 

Method. — Separate  whites  and  yolks  of  eggs.  Add  to 
whites  salt  to  taste.  Beat  whites  until  very  thick.  Beat 
yolks  until  thick  and  lemon  colored.  Combine  and  beat 
with  egg-beater.  Fold  in  gradually  one  box  of  Lister's 
Diabetic  Flour.  Divide  into  six  parts  if  Lister's  Baking 
Biscuit  Tins  are  used.  Have  oven  moderately  hot.  If 
baked  in  gas-stove  oven,  bake  from  fifteen  to  twenty  minutes. 
If  baked  in  coal  or  wood  oven,  bake  from  fifteen  to  thirty 
minutes.  Do  not  open  oven  door  until  biscuits  are  done. 
Do  not  remove  from  tin  until  partly  cooled.     If  desired 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     129 

these  biscuits  may  be  flavored  to  taste  with  nutmeg,  cin- 
namon, ginger  or  cloves.  If  the  biscuits  are  to  be  kept  for 
several  hours,  wrap  them  in  a  cloth. 

FRENCH  TOAST. 

1  Egg 

2  or  3  tablespoonfuls  cream 
Lister's  Muffins,  Biscuits  or  Bread 

Beat  the  egg  and  cream  together.  Slice  Lister's  Muffins, 
Biscuits  or  Bread.  Soak  the  slices  in  the  egg  and  cream  and 
fry  in  a  little  hot  butter  until  light  brown. 

Follow  all  directions  exactly  as  given.  The  batter  may 
appear  to  be  too  thick  or  heavy  but  no  more  moisture  should 
be  added  than  is  called  for  in  these  directions. 

BAKED  SOY  BEANS. 

Yellow  Soy  beans,  120  grams,  are  soaked  for  forty-eight 
hours,  then  boiled  for  about  half  an  hour  and  finally  baked 
.with  30  grams  pork  for  twelve  hours.  The  food  value  is 
approximately  as  follows: 

Carbo- 
hydrate,       Protein,  Fat, 
grams.         grams.             grams. 

Soy  beans,  120  grams 0  48  24 

Pork,  30  grams 0  4  12 


Baked  Soy  Beans  and  Pork    ....     0  52  36 

SEA  MOSS. 

Sea  moss  farina  and  Irish  moss  are  usually  allowable  for 
diabetic  patients.  Most  of  the  carbohydrate  in  these  mate- 
rials is  in  the  form  of  pentosans  and  galactans,  which  Swartz1 
has  shown  to  be  quite  inert  in  the  body.  Unfortunately 
these  products  are  sometimes  adulterated  with  other  carbo- 
hydrates. This  emphasizes  the  fact  that  no  matter  how 
useful  a  food  may  be  in  itself,  one  must  always  be  on  the 
lookout  for  adulteration. 

1  Swartz:  Tr.  Conn.  Acad.  Arts  and  Sc,  1911,  xvi,  p.  247. 
9 


130  DIABETIC  MENU  AND  FOOD  VALUES 

HEPCO  CAKES. 
So  arranged  that  one  cake  is  equivalent  to  an  egg. 

Protein.  Fat. 

Hepco  flour,  140  grams 60  29 

Eggs  (2) 12  12 

Cream,  40  per  cent.,  60  c.c 2  24 

Butter,  10  grams 9 

74  74 

Make  twelve  cakes.  Each  cake  contains  6  grams  protein, 
6  grams  fat,  and  approximately  75  calories. 

BRAN  BISCUITS  FOR  CONSTIPATION. 

The  following  rule  was  given  me  by  Dr.  F.  M.  Allen: 

Bran 60     grams 

Salt i  teaspoonful 

Agar  agar,  powdered 6     grams 

Cold  water 100     c.c.  (|  glass) 

Tie  bran  (for  character  of  bran  to  purchase  see  p.  122)  in 
cheesecloth  and  wash  under  cold  water  tap  until  water  is 
clear.  Bring  agar  agar  and  water  (100  c.c.)  to  the  boiling- 
point.  Add  to  washed  bran  the  salt  and  agar  agar  solution 
(hot).  Mold  into  two  cakes.  Place  in  pan  on  oiled  paper, 
and  let  stand  half  an  hour;  then,  when  firm  and  cool,  bake  in 
moderate  oven  thirty  to  forty  minutes. 

The  bran  muffins  naturally  will  be  far  more  palatable  if 
butter  and  eggs  are  added.  This  may  be  done  providing 
the  patient  allows  for  this  in  the  diet.  If  the  patient  is  not 
upon  a  measured  diet,  then  considerable  latitude  can  be 
employed  in  making  the  bran  cakes. 

BRAN  CAKES  FOR  DIABETICS. 


Carbo- 

Protein, 

Fat, 

hydrate, 

Food. 
Bran 

Amount.                grams. 
2  cupfuls 

grams. 

grams. 

Calorie 

Melted  butter   . 

30  grams 

25 

225 

Eggs  (whole)  2 

12 

12 

156 

Egg  white  (1)    . 

25  grams                 3 

12 

Salt  .... 

1  teaspoonful 

Water. 

— 

— 

— 



15  37  0  393 


DIETETIC  SUGGESTIONS,   RECIPES  AND  MENUS     131 

Tie  bran  in  cheesecloth  and  wash  thoroughly  by  fastening 
on  to  the  water  tap,  until  the  water  comes  away  clear.  The 
bran  should  be  frequently  kneaded  so  that  all  parts  come  in 
contact  with  the  water.  Wring  dry.  Mix  bran,  well-beaten 
whole  eggs,  butter  and  salt.  Beat  the  egg  white  very  stiff 
and  fold  in  at  the  last.  Shape  with  knife  and  tablespoon  into 
three  dozen  small  cakes.  If  desired  one-half  gram  of  cinna- 
mon or  other  flavoring  may  be  added.  Each  cake  contains: 
protein,  0.5  gram;  fat,  1  gram;  calories,  11. 

CRACKED  COCOA. 

( 'racked  cocoa  (cocoa  nibs)  makes  a  most  useful  drink 
for  diabetic  patients.  This  is  not  generally  appreciated  by 
the  profession. 

The  sample  of  cracked  cocoa  (cocoa  nibs)  used  has  been 
purchased  of  the  S.  S.  Pierce  Co.,  Boston.  It  was  analyzed 
by  Professor  Street,  with  the  following  result : 

Moisture 2^83 

Protein 14.69 

Fat 51.42 

Fiber 4.32 

Ash 3.88 

Starch 7.48 

Reducing  sugar,  as  dextrose,  direct none 

Reducing  sugar,  as  dextrose,  after  inversion       .      .      .      .  0 .  94 

The  cocoa  is  prepared  for  the  table  by  adding  a  cupful  of 
the  cracked  cocoa  to  a  quart  of  water  and  letting  it  simmer 
on  the  back  of  the  stove  all  day,  adding  water  from  time  to 
time. 

Professor  Street  was  good  enough  to  analyze  the  infusion, 
and  wrote  me:  "The  cocoa  prepared  according  to  directions 
contained  0.032  per  cent,  of  reducing  sugar  as  dextrose 
direct  and  0.138  per  cent,  of  total  reducing  sugars." 

LEMON  JELLY  (DIABETIC). 

Carbo- 
Protein,         Fat,  hydrate, 

Food.  Amount.  grams.        grams.  grams.      Calories. 

Lemon  juice      .      .     30  c.c.  .  .  . .  3  12 

Water     ....     50  c.c. 

Gelatin  ....       4  grams  4  .  .  . .  16 

Saccharin  (to  sweeten) 

Cream,  40  per  cent.     30  c.c.  1  12  1  116 

5  12  4  144 


132  DIABETIC  MENU  AND  FOOD  VALUES 

Soften  gelatin  in  a  part  of  the  cold  water.  Heat  the  remain- 
ing water  and  lemon  juice  and  pour  over  the  gelatin.  Stir 
until  dissolved.  Add  saccharin,  strain  into  cups.  Serve  with 
cream. 

BAVARIAN  CREAM  (DIABETIC). 


Carbo- 

Protein, 

Fat, 

hydrate, 

Food.                            Amount. 

grams. 

grams. 

grams. 

Calories. 

Cream,  40  per  cent.     90  c.c. 

3 

36 

3 

348 

Water     ....      10  c.c. 

Egg  (1)   .      .      .      .50  grams 

6 

6 

78 

Gelatin  ....       2  grams 

2 

8 

Saccharin  (to sweeten) 

Flavoring  (to  taste) 

11  42  3  434 


Soften  the  gelatin  in  cold  water,  then  add  to  the  cream, 
which  has  been  heated.  Stir  until  dissolved,  pour  on  the 
beaten  egg,  cook  like  soft  custard,  turn  into  mold  and  chill. 

ICE  CREAM  (DIABETIC). 


Carbo- 

Protein, 

Fat, 

hydrate, 

Food.                                Amount. 

grams. 

grams. 

grams. 

Calories. 

Cream,  40  per  cent.     90  c.c. 

3 

36 

3 

348 

Water     ....      10  c.c. 

Egg  (1)  .      .      .      .50  grams 

6 

6 

78 

Saccharin  (to  sweeten) 

Flavoring  (to  taste) 

— 

— 

— 



9  42  3  426 

Make  a  soft  custard  of  the  egg,  50  c.c.  of  the  cream,  and 
the  water.  Whip  the  remaining  40  c.c.  of  cream  and  fold  into 
custard.  The  saccharin  may  be  added  to  the  egg.  The 
flavoring  should  be  added  last. 

AGAR  AGAR  JELLY. 

One-quarter  of  an  ounce  sufficient  to  make  one  quart  of 
jelly.    Agar  agar  may  also  be  added  to  broths. 

Miss  E.  Grace  McCullough,  Dietitian  at  the  Peter  Bent 
Brigham  Hospital,  has  given  me  several  practical  suggestions 
about  the  preparation  of  hospital  diabetic  diets.  Many  of 
these  have  been  incorporated  in  what  follows. 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     133 

THRICE-COOKED  VEGETABLES. 

The  vegetables  are  cleaned,  cut  up  fine,  soaked  in  cold 
water  and  then  strained.  The  vegetables  are  then  tied  up 
loosely  in  a  large  square  of  double  cheesecloth — large  enough 
so  that  the  corners  of  the  cloth,  after  it  has  been  tied  up 
with  a  string,  make  conveniently  long  ends,  and  also  large 
enough  to  allow  the  vegetables  to  swell  without  sticking 
together.  They  are  then  transferred  to  fresh  cold  water, 
placed  on  the  fire,  and  brought  to  the  boiling-point,  at  which 
temperature  they  are  maintained  for  from  three  to  five  min- 
utes. This  water  is  then  poured  off  and  replaced  by  fresh, 
and  the  vegetables  again  boiled  a  similar  length  of  time. 
Three  changes  of  water  are  usually  sufficient  to  remove  the 
carbohydrate,  as  has  been  proved  by  Professor  Wardall's 
preliminary  experiments.  The  pots  for  the  vegetables  should 
be  of  sufficient  size  to  hold  a  large  quantity  of  water,  and 
in  a  hospital,  vegetables  enough  for  the  daily  supply  of  six 
patients.  Vegetables  thus  cooked  will  keep  in  cold  storage 
two  or  more  days,  and  the  reheating  of  the  same  in  a  steamer 
"is  a  simple  affair. 

If  the  vegetables  are  cooked  with  the  cover  left  off  the  pot 
they  will  be  lighter  in  color  and  the  flavor  not  so  strong. 

Miss  McCullough  has  adopted  several  expedients  by  which 
variety  in  the  5  per  cent,  vegetables  is  obtained,  and  thus  the 
monotony  of  the  diet  avoided.  She  suggests  that  the  large 
outer  stalk — slightly  green  covering — of  cauliflower  be  care- 
fully cleaned,  cut  into  half-inch  pieces  and  boiled  until  tender, 
and  frequently  this  is  transferred  from  four  waters.  Similarly 
the  green  outside  leaves  and  any  small  pieces  of  lettuce  may 
be  shredded  and  served  like  spinach.  Chard  in  season  can  be 
purchased  by  the  bushel,  cut,  and  then  chopped  up.  Rhu- 
barb retains  its  acid  flavor  and  has  proved  so  acceptable  an 
addition  to  the  diet  that  in  the  future  it  should  be  canned  by 
the  cold-water  method  for  subsequent  use.  The  flat,  large, 
celery  stalks  with  any  or  all  the  leaves,  whether  yellow  or 
green,  chopped  fine,  serve  excellently  well.  White,  green,  and 
red  cabbage  is  cut  fine  and  served  as  cold  slaw. 

Diabetic  patients  should  be  urged,  whenever  possible,  to 


134  DIABETIC  MENU  AND  FOOD   VALUES 

have  a  garden  and  to  raise  suitable  vegetables  for  themselves 
for  the  ensuing  winter.  One  of  my  patients  does  this  and 
thus  provides  himself  with  the  best  of  celery,  cabbage,  lettuce, 
etc.  This  patient  eats  a  slice  of  cabbage,  cut  as  one  buys 
cheese  in  a  grocery  store,  for  breakfast  each  morning,  and 
by  this  means  keeps  the  bowels  perfectly  regular. 

Canned  vegetables  which  have  been  of  the  most  service 
at  the  Peter  Bent  Brigham  Hospital  are  of  four  varieties: 
soup  asparagus,  broad,  flat,  cut  string  beans,  the  tender, 
green,  stringless  bean,  and  the  white  wax  beans.  The  pods 
are  separated  from  the  beans,  the  latter  being  used  for  the 
benefit  of  other  patients.  Soup  asparagus  proved  to  be 
excellent  for  hospital  use.  It  is  a  by-product  of  the  factory 
and  consists  of  the  broken-oft'  tips  and  the  shorter  thin  stalks 
which  are  unfit  for  the  standard  size.  The  pieces  are  about 
one  inch  long  and  are  all  edible. 

SQUAB. 

A  squab  when  carefully  boned  yields  50  grams  of  meat. 
This  is  broiled  in  an  oiled  paper  case  to  prevent  evaporation, 
and  when  served  with  the  escaped  juices  proves  a  favorite 
dish  for  patients.  It  contains  about  12  grams  protein  and 
5  grams  fat. 

BOILED  DINNER. 

Corned  heef,  with  cabbage  and  one  other  vegetable,  served j 
together  as  a  boiled  dinner,  is  most  acceptable  to  male 
patients.  A  portion  containing  50  to  75  grams  of  meat  and 
100  grams  of  each  vegetable  makes  an  excellent  meal. 
Corned-beef  hash  made  of  meat  and  vegetables  in  the  same 
proportion  could  also  be  served  for  variety. 

The  proper  seasoning  of  the  food  is  a  great  help  to  the 
diabetic  patient.  So  many  articles  are  excluded  from  the 
diet  that  the  great  variety  which  is  possible  in  the  prepara- 
tion of  the  food  by  the  help  of  seasoning  is  overlooked. 
Horseradish,  to  be  sure,  contains  10  per  cent,  of  carbohydrate, 
but  it  would  take  at  least  two  teaspoonfuls  to  contain  a 
gram,  and  probably  far  more.     Sour  pickles  are  allowable, 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     135 

and  other  pickles  made  from  the  group  of  5  per  cent,  vege- 
tables, provided  one  is  assured  that  they  have  been  prepared 
without  sweetening.  Mint,  capers,  curry,  tarragon  vinegar, 
onion,  bay  leaf  and  cloves  may  all  be  used  as  seasoning,  and 
tomato  and  onion  stewed,  to  which  bay  leaf  and  cloves  may 
be  added  and  then  thickened  with  Irish  moss,  serves  as  a 
sauce. 

SEVEN  MENUS  FOR  A  SEVERE  DIABETIC. 

For  the  menus  and  the  recipes  which  make  them  possible 
I  am  greatly  indebted  to  Miss  Alice  Dike,  Instructor  in 
Household  Economics  at  Simmons  College,  and  to  Case 
Xo.  765.    The  directions  given  were  as  follows: 

Carbo- 
hydrate,    Protein,  Fat, 
Daily  dietetic  prescription.1                                  grams.       grams.          grams. 

Five  per  cent,  vegetables,  300  grams  10  5  0 

Eggs,  2 0  12  12 

Bacon,  30  grams 0  5  15 

Butter,  30  grams 0  0  25 

Cream,  60  grams,  40  per  cent 2  2  24 

Meat,  120  grams 0  32  20 

Lister  roll  (2)         0  .  12  12 

12  68  108 

The  calories  furnished  amount  to  about  1200 — a  main- 
tenance diet  for  a  patient  weighing  40  kilograms  and  a 
sufficient  diet  for  a  patient  of  50  kilograms  when  in  bed. 

FIRST  DAY. 
Breakfast. 

Soft-boiled  egg,  1. 
Fried  bacon,  30  grams. 
Lister  roll  and  butter,  8  grams. 
Coffee  and  cream,  30  grams. 

Lunch. 

Roast  beef,  60  grams;  grated  horseradish. 

String  beans,  75  grams,  and  butter,  7  grams. 

Lettuce  and  cucumber  salad,  50  grams. 

Rhubarb  jelly  and  meringue  (rhubarb,  25  grams,  and  §  white  of  egg). 

1  These  represented  the  dietetic  orders  for  one  week,  and  from  the  foods 
mentioned  in  the  list  the  menus  which  follow  were  prepared. 


136  DIABETIC  MENU  AND  FOOD  VALUES 

Dinner. 

Chicken,  60  grams. 

Cauliflower,  75  grams,  and  butter,  7  grams. 

Celery  and  olives,  75  grams. 

Lister  roll  and  butter,  8  grams. 

Coffee  Spanish  cream  (egg  1  and  cream  30  grams). 

SECOND  DAY. 

Breakfast. 

Shirred  egg,  1. 

Fried  bacon,  20  grams. 

Lister  roll  and  butter,  8  grams. 

Coffee  and  cream,  30  grams. 

Lunch. 

Boiled  haddock,  60  grams. 

Cucumber  sauce,  25  grams. 

Butter,  6  grams. 

Spinach,  75  grams,  and  butter,  8  grams,  and  5  egg. 

Lettuce,  30  grams. 

Coffee  jelly  whip. 

Dinner. 

Lamb  chops,  60  grams;  tomato  sauce,  45  grams. 
Asparagus,  75  grams  and  butter,  8  grams. 
Dandelion  greens,  50  grams,  and  bacon,  10  grams. 
Lister  cream  puff  and  custard. 

THIRD  DAY. 
Breakfast. 

Egg,  1 ;  scrambled  with  tomato,  50  grams. 

Bacon,  20  grams. 

Lister  roll  and  butter,  8  grams. 

Coffee  and  cream,  30  grams. 

Lunch. 

Vegetable  hash  (corned  beef,  40  grams;  cabbage,  80  grams;  onions,  10  grams; 

beet,  10  grams;  bacon,  10  grams). 
Lettuce,  30  grams. 
Lister  roll  and  butter,  8  grams. 
Tea. 

Dinner. 

Steak,  80  grams,  and  butter,  7  grams. 

Broiled  pepper,  25  grams. 

Cauliflower,  75  grams,  and  butter,  7  grams. 

Wine  jelly  and  egg  and  cream  sauce  (egg,  1,  and  cream,  30  grams). 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     137 

FOURTH  DAY. 

Breakfast. 

Liver,  40  grams,  and  bacon,  15  grams. 
Lister  roll  and  butter,  10  grams. 
Coffee  and  cream,  15  grams. 

Lunch. 

Ham  omelet  (egg,  1 ,  and  meat,  20  grams) . 

Bacon,  15  grams. 

Salad,  150  grams  (celery,  cabbage,  lettuce). 

Lister  roll,  butter,  10  grams. 

( 'racked  cocoa  and  cream,  15  grams. 

Dinner. 

Roast  lamb,  GO  grams,  and  mint  sauce. 
Sliced  tomatoes,  75  grams. 
String  beans,  75  grams,  and  butter,  10  grams. 
Vanilla  ice-cream  (egg,  1,  and  cream,  30  grams). 

FIFTH  DAY. 
Breakfast. 

Scrambled  egg,  1,  and  dried  beef,  20  grams. 
Lister  roll  and  butter,  6  grams. 
Coffee  and  cream,  20  grams. 

Lunch. 

Spinach  soup  (spinach,  25  grams;  cream,  15  grams;  yolk  1  egg,  stock). 

Bacon,  30  grams;  fried  with  egg  plant,  125  grams. 

Coffee. 

Dinner-,. 

Steak,  100  grams,  and  water  cress,  25  grams;  "Maitre  d'Hotel"  butter,  10 

grams. 
Vegetable  marrow,  125  grams,  and  butter,  8  grams. 
Lister  roll  and  butter,  6  grams, 
("rucked  cocoa  whip  (white  1  egg  and  cream,  25  grams). 

SIXTH  DAY. 
Breakfast. 

Fried  fish  cakes  and  butter,  6  grams  (fish,  40  grams;  egg,  1 ;  cream,  15  grams). 
Sliced  cucumbers  on  lettuce,  75  grams. 
Coffee  and  cream,  15  grams. 


13S  DIABETIC  MENU  AND  FOOD  VALUES 


Lunch. 

Fried  egg,  1,  and  bacon,  30  grams. 
Lister  roll  and  butter,  10  grams. 
Cold  slaw,  75  grams. 
Tea. 

Dinner. 

Broiled  swordfish,  80  grams  (drawn  butter  sauce,  7  grams,  and  parsley). 

Brussels  sprouts,  100  grams,  and  butter,  7  grams. 

Tomato  jelly  salad,  50  grams. 

Lister  roll  and  whipped  cream,  30  grams  (flavored  with  coffee). 


SEVENTH  DAY. 

Fasting. 

RECIPES  USED  IN  PREPARING  THE  PRECEDING  MENUS. 
Grated  Horseradish  Sauce. 

H  teaspoonfuls  grated  horseradish. 

5  teaspoonful  vinegar. 

I  teaspoonful  salt. 
Cayenne. 

2  teaspoonfuls  cream  or  water. 
Mix  first  four  ingredients  and  add  cream  beaten  stiff. 

Cucumber  Sauce. 

Grate  25  grams  cucumber  and  season  with  salt,  pepper  and  vinegar. 

Tomato  Sauce. 

Stew  45  grams  tomato,  season  with  salt,  pepper,  clove  and    bay  leaf. 
Irish  or  sea  moss  may  be  used  for  thickening. 

Parsley  Sauce. 

7  grams  butter. 
1  teaspoonful  chopped  parsley. 
Salt  and  pepper. 
Add  parsley  to  melted  butter  just  before  serving. 

Mint  Sauce. 

|  cup  finely  chopped  mint  leaves. 
i  cup  vinegar. 
1  grain  saccharin. 
Add  saccharin  to  vinegar  and  dissolve,  pour  over  mint  and  let  stand  thirty 
minutes  on  back  of  range.     Let  cool  before  serving. 


DIETETIC  SUGGESTIONS,   RECIPES  AND  MENUS     139 
Maitre  d 'Hotel  Butter. 

10  grams  butter. 
Salt  and  pepper. 
1  teaspoonful  chopped  parsley. 
5  teaspoonful  lemon  juice. 
Put  butter  in  bowl  and  with  wooden  spoon  work  until  creamy.    Add  season- 
ing and  lemon  juice  slowly. 

Coffee  Spanish  Cream. 

1  scant  teaspoonful  gelatin  soaked  in  1   tablespoonful  cold  water  and 

dissolved  in  5  tablespoonfuls  hot  coffee. 
Add  30  grams  cream  and  pour  on  slightly  beaten  yolk  of  egg. 
( 'ook  like  soft  custard  and  pour  while  hot  on  stiffly  beaten  white  of  egg. 
Saccharin. 

Rhubarb  Jelly  with  Meringue. 

1  teaspoonful  gelatin  soaked  in  1  tablespoonful  cold  water  and  dissolved 
in  sauce  made  by  cooking  rhubarb  in  enough  water  to  make  7  table- 
spoonfuls. 

Serve  garnished  with  beaten  white  of  egg  flavored  with  vanilla. 

Saccharin. 

Coffee  Jelly  Whip. 

Make  the  same  as  plain  coffee  jelly,  but  just  before  it  hardens  beat  in  an 
egg  beaten  until  fluffy. 

Saccharin. 

Lister  Cream  Puff. 

Lister  biscuit  with  soft  custard  poured  over  it.    The  soft  custard  is  made 

as  follows: 
30  grams  cream. 
h  egg. 

2  tablespoonfuls  water. 
Saccharin  and  flavoring  as  desired. 

Wine  Jelly  with  Custard  Sauce. 

1  scant  teaspoonful  gelatin  soaked  in   1    teaspoonful  cold  water  and 
dissolved  in  4  tablespoonfuls  boiling  water  and  flavored  with  3  table- 
spoonfuls wine  and  saccharin. 
Serve  with  sauce  used  above  for  Lister  cream  puff. 

Cracked  Cocoa  Whip. 

1   scant  teaspoonful  gelatin,  soaked  in  1  tablespoonful  water,  dissolved 

in  5  tablespoonfuls  strong  hot  cocoa. 
When  cooled  to  the  consistency  of  thick  cream,  pour  slowly  on  the  beaten 

white  of  an  egg,  beating  all  the  time.     Mold  and  chill. 


140  DIABETIC  MENU  AND  FOOD  VALUES 

Spinach  Soup. 

25  grams  spinach. 

15  grams  cream. 

Yolk  of  1  egg. 

|  cup  beef  or  chicken  stock. 
Add  stock  to  cooked  spinach  and  cook  five  minutes.  Then  rub  through  sieve. 
Beat  yolk  of  egg  with  cream.     Add  spinach  and  stock  and  return  to 
double  boiler.    Cook  one  minute  and  serve  at  once. 

INEXPENSIVE  MENUS. 
Diet  for  Day. 

Carbo- 
hydrate,    Protein,  Fat, 
grams.        grams.          grams. 

Five    per    cent,    vegetables,    three    times 

washed,  300  grams 0  0  0 

Eggs,  2 0  12  12 

Bacon,  30  grams 0  5  15 

Oleo  or  butter,  50  grams 


0  0  41 

Lard  or  cnsco,  45  grams 

Meat,  120  grams  ...  0  32  20 

Hepco  cakes,  2 0  12  12 

0  61  100 

FIRST  DAY. 

Breakfast. 

Fried  egg,  1,  and  bacon,  30  grams. 
Hepco  cake,  1,  and  oleo,  15  grams. 
Coffee. 

Dinner. 

Boiled  dinner: 

Corned  beef,  80  grams. 

Cabbage,  150  grams. 

Oleo,  10  grams. 

Pickle. 

Hepco  cake,  1,  and  oleo,  15  grams. 

Tea  and  coffee. 

Supper. 

Vegetable  and  corned  beef  hash  with  fried  egg: 
Corned  beef,  40  grams. 
Cabbage,  150  grams. 
Oleo,  10  grams. 
Tea  or  coffee. 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     141 


SECOND  DAY. 
Breakfast. 

Egg,  1;  scrambled  with  tomato,  50  grams. 
Bacon,  15  grams. 

Hepco  cake,  1,  and  oleo,  15  grams. 
Tea  or  coffee. 

Dinner. 

Hamburg  ste&k,  80  grams. 

Onions  (30  grams)  fried  in  10  grams  oleo,  60  grams. 

Greens,  90  grams,  with  egg,  1,  and  oleo,  10  grams. 

Hepco  cake,  1,  and  oleo,  15  grams. 

Tea  or  coffee. 

Supper. 

Meat  (liver),  40  grams,  with  bacon,  15  grams. 

Cold  slaw,  100  grams  (cabbage,  vinegar,  salt,  pepper). 


THIRD  DAY. 

Breakfast. 

Boiled  egg,  1. 

Bacon,  30  grams. 

Hepco  cake,  1,  and  oleo,  15  grams. 

Coffee. 

Dinner. 

Boiled  cod,  80  grams,  with  oleo,  10  grams,  and  vinegar. 
String  beans,  150  grams,  and  oleo,  10  grams. 
Hepco  cake,  1,  and  oleo,  15  grams. 

Supper. 

Sardines,  40  grams,  with  hard-boiled  eggT  1. 
Sauerkraut,  150  grams. 
Tea  or  coffee. 

PICNIC  LUNCHES. 

FIRST  DAY. 

Dinner. 

Lister  sandwich:   1  Lister  roll,  chicken,  60  grams,  cucumber,  75  grams. 

Hard-boiled  egg. 

Olives. 

Tea  or  coffee. 


142  DIABETIC  MENU  AND  FOOD   VALUES 

Supper. 

Sardines,  00  grams. 

Lister  roll  and  butter. 

Lettuce,  radish,  and  celery,  75  grams. 

Ripe  tomato,  50  grams. 

SECOND  DAY. 

Dinner. 

Sliced  veal  loaf  sandwiches  (1  Lister  roll). 
Dressed  cabbage,  75  grams. 
Custard  (|  egg). 
Coffee. 

Supper. 

Salad  (cold  halibut,  egg,  5,  cucumber,  75  grams). 
Lemon  or  rhubarb  jelly. 
Brazil  nuts. 

THIRD  DAY. 

Dinner. 

Cold  lamb  chop. 

Tomato. 

Olives  and  pickles. 

Lister  cream  puff. 

Supper. 

Salad:  egg. 

Lister  sandwich:  Lister  roll,  cold  bacon,  lettuce. 

Coffee  Bavarian  cream. 

FOURTH  DAY. 
Dinner. 

Egg  baked  in  tomato  with  cheese  on  top. 
Ham  sandwich:   1  Lister  roll. 
Swiss  chard. 
Coffee  jelly. 

Supper. 

Sandwich:  cold  roast  beef,  1  Lister  roll,  lettuce  and  horseradish. 
Rhubarb  sauce. 


CHAPTER   II. 
DIET  TABLES. 

The  improvement  in  the  treatment  of  diabetes  owes  much 
to  the  recent  dissemination  of  knowledge  regarding  the  com- 
position of  foods.  To  the  United  States  Government  we 
are  indebted  for  an  excellent  monograph  by  Atwater  and 
Bryant  entitled  "The  Chemical  Composition  of  American 
Food  Materials,  Bulletin  No.  28,  revised  edition,"  which  was 
first  issued  in  1906.  This  can  be  purchased  by  sending  ten 
cents  in  coin  to  the  Superintendent  of  Documents,  Wash- 
ington, D.  C.  From  this  I  have  abstracted  such  analyses  as 
are  especially  useful  in  computing  the  diets  of  both  normal 
and  diabetic  individuals  and  have  computed  the  calories 
per  100  grams  instead  of  recording  the  same  per  pound. 

Analyses  are  also  inserted  published  by  the  Connecticut 
Agricultural  Experiment  Station.  Most  of  these  analyses 
are  concerned  with  the  so-called  diabetic  foods,  but  in  some 
cases  other  analyses  are  included  as  well.  To  these  latter 
lists  the  values  of  protein  and  fat  have  been  added.  Whereas 
the  analyses  of  many  so-called  diabetic  foods  are  recorded, 
no  special  food  is  recommended.  In  general  the  cost  of  these 
special  foods  is  greater  than  that  of  the  common  foods 
selected  from  the  ordinary  diet;  fn  fact,  the  patient  pays  for 
the  taste.  Each  physician  must  decide  the  merits  of  any 
particular  food  for  himself. 

The  arrangement  of  the  analyses  is  as  follows: 

Foods.  Page. 

Vegetables 144 

Fresh 144 

Canned 145 

Fruits  and  Berries 146 

Fresh 146 

Canned 147 

Dried 147 

Pickles  and  Condiments 147 


144  DIABETIC  MENU  AND  FOOD  VALUES 

Foods.  Page. 

Nuts 148 

Dairy  Products 149 

Milk 149 

Butter 149 

Peanut  butter 149 

Fats  and  oils        .      .            149 

Cheese 149 

Meat 150 

Fish 150 

Fresh 150 

Preserved  and  canned 150 

Shell-fish 151 

Gelatin 151 

Eggs 151 

Soups 151 

Home-made ....  151 

Canned 151 

Flours,  Meals,  Bread,  Pastry,  etc 152 

Pastes 154 

Miscellaneous 154 

Non-alcoholic  Beverages 154 

So-called  Diabetic  Preparations         155 

Flours  and  meals 155 

Breakfast  foods,  macaroni,  noodles,  etc 157 

Milk,  sugar-free 158 

Soft  breads 158 

Hard  breads  and  bakery  products 159 

Wines 162 

Dry 162 

Sweet 162 

Especially  low  in  carbohydrate 163 

Other  alcoholic  beverages 164 


Vegetables:  Fresh. 

Protein, 
per  cent. 

Rhubarb 0.6 

Endive 1.0 

Vegetable  marrow 0.1 

Sorrel 

Sauerkraut 1.7 

Beet  greens,  cooked 2.2 

Celery 0.9 

Tomatoes 0.9 

Brussels  sprouts 1.5 

Watercress 0.7 

Sea-kale 1.4 

Okra 1.6 

Cauliflower 1.8 


Caloric 

Carbo- 

value 

Fat, 

hydrates, 

per  100 

per  cent. 

per  cent. 

grams. 

0.7 

2.5 

19 

0.0 

2.6 

15 

0.2 

2.6 

13 

3.0 

12 

0.5 

3.0 

24 

3.4 

3.2 

54 

0.1 

3.3 

18 

0.4 

3.3 

21 

0.1 

3.4 

21 

0.5 

3.7 

23 

0.0 

3.8 

21 

0.2 

4.0 

25 

0.5 

4.3 

30 

DIET  TABLES 


145 


Caloric 

Carbo- 

value 

Protein, 

Fat, 

hydrate, 

per  100 

per  cent. 

per  cent. 

per  cent. 

grams. 

Egg  plant     . 

1.2 

0.3 

4.3 

25 

Cabbage 

(range 

3.0-  6.5 

1.6 

0.3 

4.7 

29 

Radishes 

(range 

2.7-  7.5 

1.3 

0.1 

5.0 

27 

Leeks 

1.0 

0.4 
0.4 

6.0 
6.0 

32 

Mushrooms1 

(range 

2.0-18.0 

3.5 

43 

Pumpkins    . 

(range 

3.0-14.0 

1.0 

0.1 

6.0 

30 

String  beans 

(range 

3.9-10.0 

2 . 3 

0.3 

6.0 

37 

Turnips 

(range 

2.3-18.0, 

1.3 

0.2 

6.0 

32 

0.1 

6.3 

7.0 

26 

Kohl-rabi     . 

(range 

3.5-14.0 

2.0 

38 

Oyster  plant 

1.2 

0.1 

7.0 

35 

Rutabagas    . 

(range 

3.0-12.0 

1.3 

0.2 

7.0 

36 

Truffles  .      .      . 

9.1 

0.5 
0.5 

7.0 
8.0 

71 

Squash    . 

(range 

3.0-15.0; 

1.4 

43 

Beets 

(range 

e.o-io.o; 

1.6 

0.1 

9.0 

44 

Carrots  . 

(range 

5.9-11.5] 

1.1 

0.4 

9.0 

45 

Onions    . 

(range 

4.0-14.0) 

1.6 

0.3 

9.0 

46 

Parsnips 

(range 

6.0-14.0) 

1.6 

0.5 

11.0 

56 

Chicory 

15.0 

62 

7  0 

0.5 
0.2 

15.0 
16.0 

95 

Artichokes2 

2.6 

78 

1.1 
1.1 

16.0 
19.0 
20.0 

66 

Corn 

3.1 

101 

Potatoes 

(range 

13.0-27.0) 

2  2 

101 

Lima  beans 

7.1 

0.7 

22.0 

126 

Sweet  potatoes 

(range 

16.5-44.5) 

1.8 

0.7 

26.0 

120 

Soy  beans?   . 

(range 

L9. 3-39.0) 

20.0 

43.0 

28.0 

467 

Lettuce  . 

1.2 

0.3 
0.2 
0.3 

2.2 
2.3 

2.3 

17 

0.8 

15 

Spinach 

2.1 

21 

Asparagus    . 

1.8 

0.2 

2.4 

19 

Vegetables:  Canned. 


Beans,  haricot-verts ~-l .  1 

Asparagus    .      .      .      (range     1.6-3.3)  1.5 

Brussels  sprouts 1.5 

Okra 0.7 

Tomatoes     .      .      .      (range    1.0-4.5)  1.2 

String  beans       .      .      (range    1.5-4.5)  1.1 
Macedoine,      mixed 

vegetables      .      .      (range     1.9-5.0)  1.4 


0.1 

2.0 

14 

1.1 

2.3 

26 

0.1 

2.9 

19 

0.1 

2.9 

16 

0.2 

3.0 

19 

0.1 

3.3 

19 

0.0 


3.9 


1  The  carbohydrate  which  these  contain  is  to  a  considerable  extent 
unassimilable,  and  patients  often  eat  these  with  impunity,  as  I  have  found 
since  my  attention  was  called  to  this  fact  by  Professor  Wardall. 

2  French  artichokes.  According  to  Konig,  canned  artichokes  contain 
92.46  per  cent,  water,  0.79  per  cent,  protein,  0.02  per  cent,  fat,  4.43  per  cent, 
carbohydrates. 

3  The  carbohydrate  is  non-assimilable. 

10 


146 


DIABETIC  MENU  AND  FOOD  VALUES 


Caloric 

Carbo-  value 

Protein,  Fat,  hydrates,  per  100 

per  cent,  per  cent,  per  cent,  grams. 

Artichokes  .  .  .  (range  3.2-  6.1)  0.8  0.0  4.4  21 
Pumpkins  .  .  .  (range  3.6-7.3)  0.8  0.2  6.0  30 
Peas  ....  (range  4.3-17.2)  3.6  0.2  10.0  58 
Squash  ....  (range  3.6-12.8)  0.0  0.5  10.0  49 
Beans,  haricot- 
flageolets  .  .  (range  9.8-12.4)  4.6  0.1  11.0  65 
Lima  beans        .      .      (range    9.6-16.5)       4.0  0.3  13.0  72 

Baked  beans 6.9  2.5  17.0  121 

Red  kidney  beans 7.0  0.2  17.0  100 

Com        ....      (range  11.7-25.1)        2.8  1.2  18.0  97 

Succotash     .      .      .      (range  13.9-21.3)       3.6  1.0  18.0  98 

Beans 22.5  1.8  55.0  334 

Cow  peas 21.4  1.4  55.0  326 

Peas 24.6  1.0  58.0  348 

Lentils 25.7  1.0  59.0  357 

Lima  beans         18.1  1.5  66.0  359 

Fruits  and  Berries:  Fresh. 

Strawberries 1.0  0.6  5.0  30 

Grape  fruit .  .  6.0  25 

Alligator  pear .  .  7.0  29 

Lemons 1.0  0.9  7.0  31 

Watermelons 0.3  0.1  7.0  32 

Blackberries 0.9  2.1  8.0  56 

Cranberries 0.5  0.7  8.0  41 

Peaches 0.5  0.2  9.0  41 

Muskmelons 0.7  0.3  10.0  47 

Raspberries 1.0  ?  10.0  45 

Whortleberries 0.7  3.0  10.0  72 

Apples 0.4  0.5  11.0  71 

Pears •    .        0.4  0.6  11.0  72 

Apricots 1.1  ?  12.0  54 

Gooseberries      ........        0.4  ..  12.0  51 

Mulberries 0.3  ..  12.0  48 

Pineapples    . 0.4  0.3  12.0  54 

Currants 0.4  ..  13.0  55 

Oranges 0.9  0.6  13.0  63 

Mangoes ..  13.0  53 

Grapes 1.0  1.0  15.0    '  75 

Nectarines 0.6  ?  15.0  64 

Cherries 0.8  0.8  17.0  80 

Figs 1.5  .  .  17.0  76 

Huckleberries 0.6  0.6  17.0  78 

Plums 1.0  ..  17.0  74 

Pomegranates    .      . 1.5  1.6  17.0  91 

Prunes .0.8  ?  19.0  81 

Bananas 1.5  0.7  20.0  95 

Persimmons 0.8  0.7  32.0  141 

Dates 1.9  Trace  54.0  229 


DIET  TABLES 


147 


Oranges.1 

Protein,         Fat, 
per  cent,    per  cent. 

Florida,  average  of  seven  analyses  (soluble  portion)    . 
California,  average  of  eight  analyses  (soluble  portion) 


Carbo- 
hydrates, 
per  cent. 

8.0 
8.3 


Caloric 

value 

per  100 

grams. 

3.3 

34 


Bananas. 

Yellow 1.3           0.6  22.0 

Grape  Fruit. 

Porto  Rico,  average  of  two  analyses  (soluble  portion)       .  8.2 

California,  average  of  four  analyses  (soluble  portion)  6.9 

Florida,  average  of  four  analyses  (soluble  portion)       .      .  6.6 


101 


34 

28 

27 


Fruits:  Canned. 

Peaches         ." 0.7           0.1  11.0  49 

Blueberries 0.6           0.6  13.0  61 

Pineapples    .      .      .      (range    6.0-25.0)       0.4           0.7  15.0  70 

Apricots       . 0.9            ?  17.0  73 

Pears 0.3           0.3  18.0  78 

Cherries 1.1           0.1  21.0  92 

Crab  apples 0.3           2.4  54.0  245 

Blackberries 0.8           2.1  56.0  252 

Jams,  jellies,  preserves  and  marmalade  contain  47  per  cent,  or  more  carbo- 
hydrate. 

Fruits:  Dried. 
Contain  63  per  cent,  or  more  of  carbohydrate. 

Pickles  and  Condiments. 

Distilled  vinegar 0                0  0  0 

Cider  vinegar2 0                0  0.25  1 

Cucumber  pickles 0.5            0.3  2.7  16 

Olives,  ripe 1.7         25.9  4.3  265 

Capers 3.2           0.5  5.0  41 

Prepared  mustard .    -_4 .7            4.1  5.0  78 

Prepared      mustard 

plus  cereal      .      .      (range    4.0-15.0)       3.5            1.9  7.0  61 

Ketchup       .      .      .      (range    3.0-26.0)        l.S           0.2  10.0  50 

Spiced  salad  vinegar ■  ■  10.0  41 

Horseradish 1.4           0.2  11.0  53 

Chili  sauce  .      .      .      (range  14.0 -28.0)        ..               ..  20.0  82 

Spiced  pickles 0.4           0.1  21.0  89 

Olives,  green^ 2.1          12.9  1.8  137 

Olives,  ripe 2.0         21.0  4.0  220 

Peppers  (paprica),  green,  dried    .      .      .      15.5            8.5  63.0  400 

1  If  carbohydrate  in  oranges  is  reckoned  at  10  per  cent.,  comparatively 
little  error  will  result. 

2  Professor  Street  writes  (November  27,  1916),  "In  our  last  examination 
of  27  brands  we  found  the  reducing  sugars  to  range  from  0.27  to  1.52  per 
cent." 

3  Univ.  Calif.  College  Agriculture,  1916.     Personal  communication. 


148 


DIABETIC  MENU  AND  FOOD  VALUES 


Nuts. 

Caloric 

Carbo-  value 

Protein,  Fat,  hydrates,  per  100 

per  cent,  per  cent,  per  cent,  grams. 

Filberts 15.6  65.3  13.0  724    . 

Hickory  nuts 15.4  67.4  11.4  736 

Peanuts 25.8  38.6  24.4  563 

Pecans 11.0  71.2  13.3  760 

Pine  nuts;  pignolias 33.9  49.4  6.9  626 

Pistachios,  first  quality,  shelled   .       .       .      22.3  54.0  16.3  659 

Walnuts,  California 18.4  64.4  13.0  726 

Walnuts,  California,  black      .       .       .       .      27.6  56.3  11.7  683 

Walnuts,  California,  soft  shell      .      .      .      16.6  63.4  16.1  723 

Almonds 21.0  54.9  17.3  667 

Brazil 17.0  66.8  7.0  364 

Butternuts 27.9  61.2  3.5  95 

Chestnuts,  fresh 6.2  5.4  42 . 1  248 

Cocoanuts 5.7  50.6  27.9  607 


Calcu- 

Nut Preparations. 

Protein, 
per  cent. 

Fat, 
per  cent. 

Carbo- 
hydrate 
per  cent. 

Starch, 
per  cent. 

lated 
calories 
per  100 
grams. 

The    Kellogg    Food    Co., 

Battle  Creek,  Mich.: 

1913 

Nut    Bromose    (Meltose 

and  Nuts)    .... 

17.1 

26.8 

39.4 

3.2 

467 

1906 

Nut  Butter  (Sanitas) 

28.8 

50.5 

13.9 

9.11 

625 

1906 

Nut  Meal  (Sanitas)    . 

29.0 

51.7 

12.1 

8.91 

630 

1906 

Nuttolene  (Sanitas)   . 

12.7 

21.8 

6.3 

272 

1906 

Protose  (Sanitas) 

22.6 

9.2 

3.6 

188 

1913 

Nashville  Sanitarium  Food 
Co.,   Nashville,   Tenn. : 

Nut  Butter      .... 

28.0 

52.6 

13.0 

3.8 

637 

1913 

Nutcysa 

12.9 

21.0 

6.3 

trace 

266 

1913 

Nutfoda 

Malted  Nuts. 

20.8 

8.0 

6.8 

trace 

182 

1901 

The    Kellogg    Food    Co., 
Battle     Creek,     Mich.: 

Malted  Nuts  .... 

23.7 

27.6 

43.9 

519 

1913 

Nashville  Sanitarium  Food 
Co.,     Nashville,     Tenn.: 

Malted  Nut  Food       .      . 

24.7 

42.7 

27.5 

3.4 

593 

1  Determined  by  the  diastase  method,  without   previous  washing   with 
water,  and  calculated  as  starch. 


DIET  TABLES 


149 


Dairy  Products,  etc. 

Protein, 
per  cent. 

Milk,  whole 3.3 

Milk,  condensed,  sweetened    .      .      .      .  8.8 
Milk,  condensed,  unsweetened,  "evapo- 
rated cream" 9.6 

Milk,  skimmed 3.4 

Cream,  approximately  20  per  cent,  fat  .  2.31 

Cream,  40  per  cent,  fat 1.51 

Buttermilk 3.0 

Whey ' .      .  1.0 

Kephir 3.1 

Koumiss 2.8 


Butter 
1913    S.   S.   Pierce  Co., 
Acharis       Brand 
butter  . 


Boston: 
peanut 


Protein,       Fat, 
percent,  percent 

1.0        85.0 


Carbo- 
hydrate    Starch, 
percent,  percent. 


Caloric 

value 
per  100 
grams. 

793 


28.7        48.3        14.6        5.1  608 


Oils  and  Fats. 
Lard,       tallow,       oleomar- 
garine, cod-liver  oil,  olive 
oil   and   other  edible  oils 
(crisco,  oleo.     E.  P.  J.)    . 


Cheese,  American,  pale 
"  red 
"  Camembert 
"  Cottage 
"  Dutch  .  . 
"  Full  cream 
"  Limburger 
"  Neufchatel 
"  Pineapple  . 
"  Roquefort 
"  Skimmed  milk 
"       Swiss    . 


85  to 

900 

100 

Protein, 
per  cent. 

Fat, 
per  cent. 

Carbo- 
hydrates, 
per  cent. 

Caloric 
value 
per  100 
grams. 

28.8 

35.9 

0.3 

452 

29.6 

38.3 

476 

-21.0 

21.7 

290 

20.9 

1.0 

4.3 

112 

17.7 

316 

25.9 

33.7 

2.4 

429 

23.0 

29.4 

0.4 

369 

18.7 

27.4 

1.5 

337 

29.9 

38.9 

2.6 

494 

22.6 

29.5 

1.8 

374 

31.5 

16.4 

2.2 

290 

27.6 

34.9 

1.3 

442 

1  Estimated,  E.  P.  J. 


150 


DIABETIC  MENU  AND  FOOD  VALUES 


Meat. 

Protein, 
per  cent. 

Beef,  cooked: 

Roast 22.3 

Round  steak,  fat  removed        .      .      .  27 . 6 

Calf's  foot  jelly 4.3 

Beef,  canned: 

•     Dried  beef 39.2 

Beef,  corned  and  pickled: 

Corned  beef,  all  analyses    .      .      .      .  15.6 

Mutton,  cooked: 

Mutton,  leg  roast 25.0 

Pork,  pickled,  salted  and  smoked: 

Ham,  smoked,  lean 19.8 

Bacon,  smoked,  all  analyses     .      .      .  10.5 

Sausage,  A: 

Bologna  sausage       (range    0.2-3.1)  18.7 
Frankfort       .      .      (range    0.0-6.6)  19.6 
Pork      (range  carbohydrate  0 . 0-8 . 6)  13.0 
Deerfoot  Farm,  cooked,  analysis  fur- 
nished by  the  manufacturers      .      .  19.93 

Poultry  and  game,  fresh: 

Chicken,  broilers 21.5 

Fowls 19.3 

Goose,  young 16.3 

Turkey 21.1 

Liver : 

Beef 21.0 

Chicken,  as  purchased 22.4 

Goose,  as  purchased 16.6 

Mutton,  as  purchased 23.1 

Pork,  as  purchased 21.3 

Turkey,  as  purchased 22.9 

Veal,  as  purchased 19.0 

Fish:  Fresh. 

Cod  sections 16.7 

Flounder,  whole 14.2 

Haddock,  entrails  removed     .      .       .      .  17.2 

Halibut,  steaks  or  sections      .      .      .       .  18.6 

Mackerel,  whole 18.7 

Salmon,  whole 22.0 

Shad,  whole 18.8 

Trout  (brook),  whole         19.2 


Fat, 
per  cent. 

Carbo- 
hydrates, 
per  cent. 

Caloric 

value 

per  100 

grams. 

28.6 

356 

7.7 

185 

0.0 

17.0 

87 

5.4 


26.2 


22.6 


20.8 
64. 8' 

17.6 
18.6 

44.2 


54.21 

2.5 
16.3 
36.2 
22.9 

4.5 
4.2 
15.9 
9.0 
4.5 
5.2 
5.3 


0.3 

0.6 
0.3 
5.2 
7.1 
12.8 
9.5 
2.1 


0.6 

1.1 
1.1 


1.7 
2.4 
3.7 
5.0 
1.4 
0.6 


211 

307- 

312 

274 
645 

243 

258 
468 


0.34       587 

111 
230 
403 

299 


133 
141 
231 
199 
135 
144 
127 


72 

64 

74 

124 

142 

209 

165 

98 


Fish:  Preserved  and  Canned. 

Cod,  salt,  "boneless"         27.3  0.3 

Herring,  smoked 36.9  15.8 

Sardines,  canned 23.0  19.7 

Shad  roe 20.9  3.8 

Sturgeon  caviare 30.0  19.7 


2.6 
8.0 


108 
298 
277 
121 
198 


DIET  TABLES 


151 


Shell-fish. 

Protein, 

per  cent . 

Clams,  long,  in  shell 8.6 

Crabs,  hardshell,  whole 16.6 

Lobster,  whole 16.4 

Mussels,  in  shell 8.7 

Oysters,  in  shell 6.2 

Scallops,  as  purchased 14.8 

Terrapin 21.2 

Turtle,  green,  whole 19.8 

Gelatin. 

Gelatin' 91.4 

Eggs. 
Eggs,  edible  portion:2 

Hens',  uncooked 13.4   , 

Hens',  boiled       .      .  .      .      .  13. 2 ^ 

Hens',  boiled  whites 12.3 

Hens',  boiled  yolks 15.7 

Soups:  Home-made 

Beef 4.4 

Bean 3.2 

Chicken 10.5 

Clam  chowder 1.8 

Meat  stew 4.6 

Soups:  Canned. 

Bouillon 2.2 

Chicken  gumbo 3.8 

Chicken  soup -_  3 . 6 

Consomme  . 2.5 

Julienne 2.7 

Mock  turtle .      .  5.2 

Mulligatawny 3.7 

Oxtail 4.0 

Pea  soup 3.6 

Tomato  soup 1.8 

Vegetable 2.9 


Fat, 
■r  cent. 

Carbo- 
hydrates, 
per  cent. 

Caloric 

value 

per  100 

grams. 

1.0 

2.0 

53 

2.0 

1.2 

91 

1.8 

0.4 

86 

1.1 

4.1 

63 

1.2 

3.7 

52 

0.1 

3.4 

76 

3.5 

120 

0.5 

86 

0.1 


10.5  / 
12.0 
0.2 
33.3 


375 


158 

168 

55 

376 


0.4 

1.1 

26 

1.4 

9.4 

65 

0.8 

2.4 

61 

0.8 

6.7 

43 

4.3 

5.5 

81 

0.1 

0.2 

11 

0.9 

4.7 

43 

0.1 

1.5 

22 

0.4 

12 

0.5 

13 

0.9 

2.8 

41 

0.1 

5.7 

40 

1.3 

4.3 

46 

0.7 

7.6 

52 

1.1 

5.6 

41 

0.5 

14 

1  I  understand  that  many  of  the  brands  of  commercial  gelatin  contain 
from  83  to  87  per  cent,  gelatin,  11  to  14  per  cent,  of  moisture  and  1  to  2 
per  cent,  of  ash.     E.  P.  J. 

2  One  egg  contains  approximately  protein  6  grams  and  fat  6  grams,  of 
which  one-half  the  protein  and  all  the  fat  are  in  the  yolk.     E.  P.  J. 


152 


DIABETIC  MENU  AND  FOOD  VALUES 


Flour,  Meals,  Bread,  Pastry,  etc. 

Caloric 

Carbo-  value 

Protein,  Fat,  hydrate,  per  100 

per  cent,    per  cent,  per  cent,  grams. 

Flours,    meals,    etc. : 

Barley  meal  and  flour 10.5           2.2  72.8  361 

Buckwheat  flour 6.4           1.2  77.9  356 

Cornmeal,  unbolted 8.4           4.7  74.0  381 

Hominy 8.3  0.6  79.0  363 

Oatmeal 16.1  7.2  07.5  409 

Rolled  oats 16.7           7.3  66.2  407 

Rice 8.0  0.3  79.0  359 

Rice,  boiled 2.8  0.1  24.4  112 

Rye  flour 6.8  0.9  78.7  359 

Wheat  flour,  California  fine      .      .      .        7.9            1.4  76.4  358 
Wheat  flour,  entire  wheat  .      .      .       .  13.8            1.9  71.9  369 
Wheat  flour,  patent  roller  process,  high 
grade  (average  of  all  analyses  of  high 
medium  grades  and  grade  not  indi- 
cated)      11.4            1.0  75.1  303 

Wheat  preparations: 

Macaroni 13.4  0.9  74.1  366 

Macaroni,  cooked 3.0            1.5  15.8  91 

Soy  bean  meal 42.5  19.9  34.0'  499 

Pea  flour 25 . 7           1.8  57.0  354 

Acorn  meal 7.3-4.9  64.0  338 

Graham  flour 13.3  2.2  70.0  362 

Pop  corn,  popped 10.7  5.0  77.0  586 

Cassava  meal 1.3            1.2  81.0  348 

Potato  starch 0.9  0.1  81.0  337 

Sago  starch 2.2  0.0  81.0  341 

tapioca  (Arrow-root) 0.1  0.1  84.0  340 

Banana  flour 3.9  1.0  85.0  375 

Cornstarch 1.2  0.0  85.0  353 

Rye 10.2  1.7  72.0  353 

Buckwheat 10.1  2.5  61.0  315 

" Ralston  Health  Food " 11.9  1.7  72.0  360 

"Quaker  Wheat  Berries"        ....  13.8  1.9  72.0  370 

"Wheatlet" 12.8  1.6  74.0  371 

"Force" 10.6  1.1  74.0  358 

Cracked  wheat 11.1  1.7  74.0  365 

"Pettijohn's  Breakfast  Food"     .      .      .  9.1  2.0  74.0  359 

"  Malt  Breakfast  Food " 13.8  1.5  75.0  378 

"Cream  of  Wheat" 11.5  0.9  75.0  353 

"Triscuit" 11.0  1.4  75.0  365 

"Grape  Nuts" 11.5  0.6  75.0  360 

Farina 11.0  1.4  75.0  367 

"Wheatena" 11.3  2.8  76.0  384 

"Mapl-Flake" 11.0  1.4  76.0  369 

"Shredded  Wheat  Biscuit"2   ....  8.3  0.6  76.0  351 

Hominy 7.6  0.2  78.0  353 

Puffed  rice 6.7  0.4  80.0  359 

Toasted  corn  flakes ..  81.0  332 

1  The  assimilable  carbohydrate  in  soy  beans  is  3  per  cent,  or  less. 

2  Weight  of  1  biscuit  30  grams,  and  it  contains  approximately,  carbohy- 
drate 23  grams  and  protein  3  grams. 


DIET  TABLES 


153 


Caloric 
Carbo-  value 

Protein,       Fat,        hydrate     Starch,     per  100 
per  cent,  per  cent,   per  cent,  per  cent,     grams. 

11913    Glidine :  Menley  &  James, 

New  York     ....      91.4  0.S  1.0  0  377 

1909    Plasmon:    Plasmon     Co., 

London 78.7  2.7  0.0  ..  339 

1915    Cotton-seed  flour:  Allison, 

Schulenburg     Oil     Mill, 

Schulenburg,  Texas        .       50.4        11.2  ..  1.1  348 


Carbo- 

Caloric 
value 

Protein, 

Fat, 

hydrate, 

per  100 

per  cent. 

per  cent 

per  cent. 

grams. 

Bread : 

5  4 

1.8 

47.1 

231 

Bread,  corn  (Johnnycake)  . 

7.9 

4.7 

46.3 

265 

9  0 

0.6 

53.2 

260 

8  9 

1.8 

52.1 

266 

Rolls,  French       ..... 

8.5 

2.5 

55.7 

286 

Rolls,  all  analyses     . 

8  9 

4.1 

56.7 

307  , 

11    5 

1.6 

61.2 

312 

White  bread,  home-made    . 

9.1 

1.6 

53.3 

270 

White  bread,  miscellaneous 

9.3 

1.2 

52.7 

266 

9  7 

0.9 

49.0 

249 

11    9 

0.6 

35.0 

198 

Peanut  bread       .... 

33  6 

12.8 

20.0 

339 

27.0 
27.0 

111 

Cassava  bread     .... 

111 

10  6 

1.3 

64.0 

318 

Crackers: 

Boston  (split)  crackers 

11.0 

8.5 

71.1 

415 

10  1 

8.8 

70.0 

399 

Graham  crackers 

10.0 

9.4 

73.8 

430 

Pilot  bread 

11.1 

5.0 

74.2 

396 

10  6 

12.7 
9.9 
8.0 

68.5 
73.5 
28.0 

441 

Zwieback 

9  8 

433 

23  2 

284 

Doughnuts  .      .      .      (range  45. 

0-63 . 0) 

G.7 

21.0 

52.0 

436 

Cake    (except   fruit 

cake)          .      .      .      (range  53 . 

J-78.0) 

6.3 

9.0 

63.0 

368 

Jumbles        .      .      .      (range  52 . 

0-7 1.0) 

7.4 

13.5 

63.0 

418 

Fruit  cake    .                   ... 

5  0 

10.9 
15.2 

64.0 
64.0 

384 

Macaroons  .      .      .      (range  57 . 

3-7 

3.0) 

6.5 

430 

1  Analysis  of  preparation  manufactured  at  this  date. 

2  Analysis  from  Conn.  Exp.  Sta.  Report,  1914,  p.  230.  One  biscuit  weighs 
7  grams  and  contains  about  5  grams  carbohydrate,  0.7  gram  protein  and 
0.5  gram  fat. 


154 


DIABETIC  MENU  AND  FOOD  VALUES 


Protein, 
Pie:  per  cenl 

Apple 3.1 

Custard 4.2 

Squash 4.4 

Mince       .      .      .      (range  30. 0-44. 6)       5.8 

Pastes. 

Noodles 13.3 

Vermicelli 10.9 

Spaghetti 12.1 


Fat, 
per  cent 

9.8 

6.3 

8.4 

12.3 


0.8 
2.0 
0.4 


Carbo- 
hydrate, 
per  cent. 

42.8 
26.1 
21.7 
38.0 


72.0 
72.0 
74.0 


Almond  Paste. 


1902-3  Chapman,  Chicago  .  . 
1902-3  Henry  Heide,  New  York 
1902-3    Spencer,  New  York  .       . 


Carbo- 
Protein,       Fat,        hydrate     Starch 
percent,  percent,  percent,  percent. 

13.1        25.5        36.3        11.3 

12.7        20.0        43.7       small 

13.5        26.2        31.6        very 

small 


Caloric 
value 
per  100 
grams. 

279 
183 
185 
194 


357 
358 
353 

Calcu- 
lated 
calories 
per  100 

grams. 

427 
406 
416 


Carbo- 
MlSCELLANEOUS.  hydrate, 

per  cent. 

Plain  chocolate 25.0 

Cocoa  nibs,  roasted 28.0 

Baking  powder  (range  0-51 .5)     32.0 

Cocoa 38.0 

Milk  chocolate 51.0 

Milk  cocoa 52.0 

Custard  powders 59.0 

Sweet  chocolate 67.0 

Carbo- 

Non-alcoholic  Beverages.  hydrate, 

per  cent. 

Tea  (0.5  oz.  to  1  pt.  water) 0.6 

Coffee  (1  oz.  to  1  pt.  water)  0.7 

Cocoa  (0.5  oz.  to  1  pt.  water) 1.1 

Cider (range  0-13 .5)       4.5 

Cocoa  (0.5  oz.  to  1  pt.  milk) 6.0 

Cream  or  lemon  soda 7.0 

Sarsaparilla 7.0 

Birch  beer 8.0 

Ginger  ale 8.0 

Root  beer 9.0 

Caloric 

Carbo-  value 

Protein,         Fat,       hydrate,  per  100 

per  cent,     per  cent,  per  cent,  grams. 

Chocolate 12.9         48.7         30.3  629 

Cocoa      ...             21.6         28.9         37.7  510 

Cereal  coffee  infusion  (1  part  boiled  in 

20  parts  water) 0.2            ..              1.4  7 


DIET  TABLES 


155 


So-called  Diabetic  Prepara- 
tions. 

a 
Cm 

a 

"5  . 

-Si*5 
^  a 

.a  o 

°  u 
Xi  o3 

o 

a 

o 

J? 

03  ft 

W 

-oftS 

Q)   to   eg 

ta'E  mi 

2  oi© 

O 

Flours  and  Meals. 

1910 

Acme  Mills  Co.,  Portland,  Ore.    . 
Amthor  &  Co.,   Halle:  Weizen- 

9.4 

1.9 

77.4 

71.4 

364 

84  1 

1.4 

4.8 

368 

1912 

Herman  Barker,  Somerville,  Mass. : 

Barker's  Gluten  Food,  "A" 

86.9 

0.5 

3.7 

trace 

370 

1913 

Barker's  Gluten  Food,  "B" 

85.1 

0.6 

7.2 

3.7 

375 

1913 

Barker's  Gluten  Food,  "C" 

84.1 

0.6 

8.6 

3.4 

377 

1914 

Battle     Creek     Sanitarium     Co., 
Battle  Creek,   Mich.,  80  per 

cent.  Gluten  Meal 

84.0 

5.8 

368 

1907 

Bischof  &   Co.,   London:    Gluten 

Flour 

79  8 

3.6 

5.0 

372 

1909 

Callard,  Stewart  &  Watt,  London: 

Casoid  Flour           '. 

82.5 

1.6 

3.1 

0 

357 

1913 

Cereo  Co.,  Tappan,  N.  Y.: 

Soy  Bean  Gruel  Flour     . 

43.1 

21.4 

24.9 

trace 

465 

1913 

Farwell    &    Rhines,    Watertown, 
N.  Y.:   . 

Gluten  Flour 

43.1 

1.2 

46.6 

38.1 

370 

1913 

Gluten  Flour 

46.3 

1.1 

42.9 

32.8 

367 

1913 

Cresco  Flour 

18.1 

1.0 

67.4 

57.2 

351 

1913 

Special  Dietetic  Food 

27.5 

2.8 

56.6 

40.0 

362 

1913 

Golden  Rod  Milling  Co. .Portland, 

Ore.,  Acme  Special  Flour 

15.8 

1.4 

71.4 

57.9 

361 

1913 

O.  B.  Oilman,  Boston,  Mass.: 

Gluten  Flour  

47.3 

2.0 

40.4 

31.4 

369 

1908 

Hazard's  Wheat  Protein    . 

41.8 

1.2 

49.1 

374 

1913 

Health  Food  Co.,  New  York: 

Almond  Meal 

50.3 

14.8 

17.9 

trace 

406 

1914 

Almond  Meal 

49.1 

21.8 

15.9 

0 

457 

1911 

O  B  X  Cold  Blast  Flour,  25  per 

- 

cent,  protein 

10.1 

0.9 

79.6 

68.9 

367 

1913 

Proniren  (Griddle-cake  Flour)    . 

37.3 

1.2 

v37.7 

349 

1913 

Glutosac  Gluten  Flour    . 

39.9 

2.3 

47.5 

36.9 

370 

1914 

Gluten  Flour  No.  1    . 

75.7 

0.9 

12.8 

7.1 

362 

1913 

Protosac  Gluten  Flour    . 

42.7 

1.7 

46.4 

36.3 

372 

1913 

Protosoy  Soy  Flour   .... 

42.3 

19.8 

24.5 

trace 

446 

1913 

Pure  Washed  Gluten  Flour  . 

80.3 

1.6 

29.5 

7.0 

380 

1914 

Gluten  Flour  

45.9 

2.0 

42.3 

31.5 

370 

1914 

Protosoy  Soy  Flour   .... 

42.9 

19.2 

26.0 

1.9 

448 

1914 

Pure  Washed  Gluten 

85.6 

1.0 

5.4 

2.8 

373 

1906 

Jireh    Diabetic    Food    Co.,    New 
York: 

1900 

Diabetic  Flour 

14.3 

2.2 

71.9 

66. 6l 

365 

1  Determined    by  the   diastase  method,   without   previous  washing  with 
water,  and  calculated  as  starch. 


156 


DIABETIC  MENU  AND  FOOD  VALUES 


So-called  Diabetic  Prepara- 

a 

c 

>>5 

a 

a  s  £ 

do 

c 

J3  o 

—  & 

C3'C  M 

tions. 

'v  t- 

u 

n" 

■§  t. 

"5°o 

■w  <v 

-  V 

—  a> 

i.  & 

o  C3© 

O    ft 

sa 

&» 

os  a 

•3OH 

Ph 

fe 

Q 

«3 

O 

Flours  and  Meals. — Continue* 

I. 

Jireh    Diabetic    Food    Co.,   Nev 

7 

York: 

1906 

Diabetic  Flour      .... 

12.1 

1.8 

72.7 

355 

1913 

Flour 

14.4 

2.3 

72.9 

60.9 

370 

1913 

Patent  Barley 

11.4 

1.6 

80.2 

67.8 

381 

1913 

Patent  Cotton  Seed  Flour 

49.4 

12.7 

21.3 

6.0 

396 

1913 

Patent  Lentils  Flour 

27.3 

1.2 

59.8 

42.6 

359 

1913 

Protein  Flour 

31.4 

2.0 

56.7 

48.5 

370 

1913 

Soja  Bean  Flour  . 

42.3 

18.2 

25.8 

0.0 

435 

1913 

Wheat  and  Barley  Flour 

11.8 

1.9 

73.5 

66. 2l 

358 

1911 

Johnson     Educator     Food     Co. 
Boston,  Mass.: 

Educator  Standard  Gluten  Flou 

r     40.1 

1.4 

50.2 

40.9 

374 

1912 

The    Kellogg    Food    Co.,    Battlt 
Creek,  Mich.: 

20  per  cent.  Gluten  Meal     . 

27.5 

0.5 

71.7 

49.6 

357 

1913 

40  per  cent.  Gluten  Flour     . 

43.7 

0.9 

47.3 

40.5 

367 

1912 

80  per  cent.  Gluten   . 

81.3 

0.9 

6.2 

365 

1913 

Eugene  Loeb,  New  York: 

Gluten  Cracker  Meal 

27.8 

7.7 

53.5 

40.2 

394 

1913 

Imported  Gluten  Flour  . 

76.3 

0.9 

11.8 

4.4 

361 

1913 

Pure  Gluten  Flour     . 

40.3 

2.4 

46.3 

39.6 

368 

1913 

Whole  Wheat  Flour  .      .      . 

14.6 

2.2 

70.5 

54.6 

360 

1913 

Gluten  Flour  

43.9 

1.1 

44.4 

39.8 

363 

1915 

Lister  Bros.,  New  York: 

Diabetic  Flour      .... 

84.5 

3.6 

0 

372 

1913 

Thos.  Martindale  &  Co.,  Phila.: 

Special  Gluten  Flour 

40.3 

1.5 

49.1 

41.4 

371 

1913 

Mayflower  Mills,  Ft.  Wayne,  Ind. 

Bond's  Diabetic  Flour    . 

40.2 

1.3 

48.3 

40.6 

366 

1913 

Theo.  Metcalf  Co.,  Boston,  Mass. 
Soja  Bean  Meal,    18  per  cent 

starch 

41.0 

20.0 

25.0 

444 

1913 

Vegetable  Gluten,  8.1  per  cent 

starch 

80.4 

1.5 

9.8 

5.9 

374 

1913 

Pieser  Livingston  Co.,  Chicago: 

1.3 

46.2 

38.4 

370 

1911 

Pure  Gluten  Food  Co.,  New  York 

1.6 

50.8 

42.4 

371 

1906 

Gum  Gluten  Ground 

50.1 

1.9 

39.6 

38. 62 

376 

1906 

Hoyt's  Gum  Gluten 

31.8 

1.6 

52. 02 

358 

1914 

Hoyt's     Gum     GJuten     Biscui 

t 

Crisps 

52.7 

0.5 

38.0 

31.2 

368 

1  Possibly  in  part  due  to  the  copper-reducing  power  of  the  agar  agar  present. 

2  Determined  by  the  diastase,  etc.  (see  preceding  page). 


DIET  TABLES 


157 


So-called  Diabetic  Prepara- 
tions. 

a 
.5  ° 

O   ft 

e 

o 

<0 

"3  . 

°  u 

.n  © 

O 

a 

o3  ft 
02 

&>  en 

o>  g  c3 
"3.2o 

o  SO 

O 

Flours  and  Meals. — Continued. 

Pure  Gluten  Food  Co.,  New  York: 

1914 

Breakfast  Food     . 

45.4 

0.9 

46.4 

39.2 

375 

1914 

Flour,  50  per  cent. 

49.7 

1.2 

41.5 

37.1 

375 

1914 

Flour,  Ground 

41.9 

0.9 

48.1 

42.6 

369 

1914 

Granules    . 

42.7 

0.7 

48.8 

41.9 

372 

1914 

Noodles 

40.5 

1.2 

49.1 

41.8 

369 

1914 

Self-raising  Flour 

42.7 

0.8 

45.0 

39.0 

357 

1914 

Special  Flour 

90.7 

0.7 

1.7 

2.2 

376 

1914 

No.  1  Dainty  Fluffs 

79.9 

0.5 

11.3 

10.7 

370 

1914 

No.  2  Dainty  Fluffs 

66.3 

0.5 

24.9 

21.9 

369 

1913 

Sprague,  Warner  &  Co.,  Chicago: 

Richelieu  Gluten  Flour  . 

47.7 

1.2 

39.7 

31.6 

368 

1913 

G.  Van  Abbott  &  Sons,  London: 

Almond  Flour 

24.6 

58.6 

7.9 

0.0 

657 

1913 

Gluten  Flour 

75.1 

0.9 

12.6 

12.4 

359 

1913 

Wilson  Bros.,  Rochester,  N.  Y. : 

Gluten  Flour,  f  Standard     . 

-20.8 

2.1 

64.6 

54.6 

361 

1913 

Self-raising,  f  Standard 

17.4 

2.0 

63.5 

51.8 

342 

1913 

Waukesha  Health  Products  Co., 
Waukesha,      Wise. :      Hepco 

Flour 

42. 91 

20.8 

22. 32 

trace 

448 

Breakfast  Foods. 

1913 

Brusson  Jeune,  Villemur,  France: 

Farine  au  Gluten       .... 

33.9 

0.6 

53.8 

48.8 

356 

1910 

Gluten  Semolina         .... 

17.2 

0.5 

71.6 

64.9 

360 

1913 

Farwell    &    Rhines,    Watertown, 
N.  Y.: 

Barley  Crystals 

11.5 

1.3 

75.2 

62.7 

359 

1913 

Cresco  Grits 

17.8 

1.4 

68.6 

54.1 

358 

1908 

Hazard's  Wheat  Protein   Break- 

40  1 

1.0 

49.7 

368 

1913 

Health    Food    Co.,    New    York: 

Manana 

37.6 

1.9 

46.8 

31.0 

355 

1913 

Jireh    Diabetic    Food    Co.,    New 
York: 

Whole  Wheat  Farina 

12.9 

2.3 

74.6 

59.5 

371 

1913 

Frumenty 

12.3 

1.7 

77.3 

65.4 

374 

1911 

The    Kellogg    Food    Co.,    Battle 

Creek,  Mich.:  Granola    . 

13.9 

0.8 

76.3 

45.2 

368 

1  Determined  by  the  diastase  method,   without  previous    washing  with 
water,  and  calculated  as  starch. 

2  Chiefly  derived  from  Soy  bean  and  therefore  non-assimilable,  and  for 
patients  can  be  considered  carbohydrate-free. 


158 


DIABETW  MENU  AND  FOOD  VALUES 


o 

a 

So-called  Diabetic  Prepara- 

a 

"5 

%£ 

"2 

2™  g 

tions. 

a  a 

° 

—  o 

8  " 

*z 

3°o 

—  &> 

i.  oj 

O   (SO 

o  a. 

ia 

s» 

a  O, 

-  o-. 

ftn 

fn 

O 

m 

o 

Breakfast  Foods. — Continued. 

1911 

Pure  Gluten  Food  Co.,  New  York: 

Gum  Gluten  Breakfast  Food     . 

37 . 8 

1.3 

51.8 

37.9 

370 

1911 

Gum  Gluten  Granules     . 

45.5 

1.6 

43.6 

32.3 

371 

1901 

Pure  Gluten  Breakfast  Cereal   . 
Waukesha  Health  Products  Co., 
Waukesha,       Wis. :       Hepco 
Grits1 

Macaroni,  Noodles,  etc. 

43.7 

1.6 

44.4 

367 

1906 

Pure  Gluten  Food  Co.,  New  York: 

Gum  Gluten  Macaroni    . 

41.4 

1.0 

46.3 

46.22 

360 

1911 

Gum  Gluten  Noodles 

36.6 

2.4 

51.4 

42.0 

374 

1910 

Brusson  Jeune,  Villemur,  France: 

Pates  aux  Ocufs  Macaroni   . 

13.9 

0.4 

76.2 

69.2 

364 

1910 

Pates  aux  Oeufs  Nouillettes 

14.4 

0.5 

75.7 

68.9 

365 

1913 

Petitcs  Pates  au  Gluten 

18.6 

1.0 

70.4 

61.2 

365 

1910 

Vermicelle  au  Gluten 

18.4 

0.4 

72.4 

65.8 

367 

1913 

Jireh    Diabetic    Food    Co.,    New 
York: 

Macaroni 

16.9 

0.9 

71.4 

58.8 

361 

1913 

Eugene  Loeb,  New  York:  Home- 

made Noodles 

41.8 

5.5 

41.7 

36.7 

384 

1913 

Gustav  Muller  &  Co.,  New  York: 

Dr.  Bouma  Sugar-free  Fat-milk3 

2.4 

5.3 

57 

1913 

D.    Whiting    &    Sons,     Boston: 
Sugar-free     Milk     (ave.     3 

5  7 

7.2 

trace 

88 

Soft  Breads. 

1913 

Ferguson  Bakery,  Boston,  Mass. : 

Gluten  Bread 

24.2 

3.1 

33.6 

25.2 

259 

1906 

Health  Food  Co.,  New  York: 

Glutosac  Bread 

27.4 

2.7 

36.1 

29.91 

278 

1914 

2.1 

31.1 

22.2 

1906 

Health  Food  Co.: 

Protosac  Bread 

32.5 

37.0 

1.6 

292 

1914 
1914 

Protosac  Bread 

J.  Heinbockel  &  Co.,  Baltimore, 
Md.: 

29.8 

1.8 

35.2 

27.7 

276 

Diabetic  Bread  for  Diabetes 

8.6 

1.5 

52.1 

40.4 

256 

1906 

Jireh    Diabetic    Food    Co.,    New 
York: 

Whole  Wheat  Bread        .      .      . 

9.4 

48.6 

0.4 

236 

1  Said  to  be  identical  with  Waukesha  Hepco  Dodgers. 

2  Determined  by  the  diastase,  etc.  (see  preceding  page). 

3  Water  91.8  per  cent. 


DIET  TABLES 


159 


So-called  Diabetic  Prepara- 
tions. 

a 
.5  ° 

a 
u 

go. 

o 

■fig 

°  u 
Si  a 

O 

C3  O. 

a>  m 

"3.2o 
O 

Soft  Breads. — Continued. 

1913 

Eugene  Loeb,  New  York: 

P.  &  L.  Genuine  Gluten  Bread 

10.4 

2.6 

53.7 

44.2 

280 

1914 

P.  &  L.  Genuine  Glubetic  Bread 

38.8 

4.1 

25.7 

19.2 

294 

1915 

Lister  Bros.,  New  York: 

Casein  Bread 

36.6 

18.4 

0 

322 

Hard  Breads  and  Bakery 

Products. 

1907 

Bischof  &  Co.,  London: 

Diabetic  Gluten  Bread    . 

73.1 

0.5 

14.3 

•• 

354 

1907 

Essential   Bread   for   Super-Ali- 

mentation     

26.6 

1.6 

59.6 

359 

1912 

Brusson  Jeune,  Villemue,  France: 

Gluten  Bread 

37.3 

1.8 

47.1 

40.1 

354 

1909 

Callard,  Stewart  &  Watt,  London: 

Almond  Biscuit,  plain     . 

28.3 

28.0 

36.8 

512 

1909 

Almond  Shortbreads 

19.5 

52.1 

27.0 

630 

1913 

Casoid  Biscuits,  No.  1     .      .      . 

66.8 

18.8 

5.8 

4.0 

460 

1909 

Casoid  Biscuits,  No.  2     .       .       . 

57.8 

25.5 

5.6 

0.0 

483 

1909 

Casoid  Biscuits,  No.  3     .       .      . 

54.3 

25.0 

7.8 

trace 

473 

1909 

Casoid  Dinner  Rolls 

78.0 

11.1 

2.1 

420 

1909 

Casoid  Lunch  Biscuit 

25.5 

44.9 

21.6 

593 

1909 

Casoid  Rusks 

37.0 

32.3 

20.8 

522 

1909 

Cocoanut  Biscuit    +   Saccharin 

16.6 

61.3 

16.4 

684 

1909 

Ginger  Biscuit  4-  Saccharin 

17.1 

58.6 

18.1 

668 

1913 

Kalari  Batons 

43.2 

39.0 

7.4 

0 

553 

1909 

Kalari  Biscuits 

56.9 

31.4 

1.7 

517 

1909 

Prolactic  Biscuit         .... 

42.9 

27.5 

19.3 

496 

1913 

Charrasse  Biscuits  Croquettes  au 

Gluten 

_34.3 

5.4 

52.3 

30.6 

395 

1913 

Biscottes  Lucullus     .... 

11.4 

5.7 

73.4 

59.2 

391 

1913 

Gluten     Exquis     Biscuits     aux 

Amandes 

18.1 

23.8 

15.6 

25.5 

489 

1913 

Gluten  Fleur  de  Neige  Pain 

35.9 

12.5 

42.8 

25.1 

427 

1913 

Mignonettes  au  Gluten  . 

40.1 

5.7 

43.6 

27.3 

386 

1913 

Pain  de  Gluten 

40.8 

5.3 

43.5 

27.2 

385 

1913 

Tranches  Grillees   pour   Potage 

40.6 

3.6 

45.5 

28.8 

377 

1913 

Health  Food  Co.,  New  York: 

Alpha  Best  Diabetic  Wafer 

66.1 

13.6 

11.3 

trace 

432 

1914 

Alpha  Best  Diabetic  Wafer 

67.1 

8.4 

11.7 

1.3 

391 

1913 

Diabetic  Biscuit 

25.0 

9.2 

54.2 

46.5 

400 

1914 

Diabetic  Biscuit 

35.9 

8.8 

46.5 

39.8 

409 

1913 

Gluten  Nuggets 

30.2 

12.8 

48.3 

38.6 

429 

160 


DIABETIC  MENU  AND  FOOD  VALUES 


So-called  Diabetic  Prepara- 
tions. 

a 

.  0J 

.5  ° 
'53  u 

2  & 

Ph 

a 

oj 
-  oj 

oj 

J3  o 
°  h 

O 

a 

03  P. 

w 

s.2o 
0  530 

a 

Hard  Breads,  etc. — Continued. 

Health  Food  Co.,  New  York: 

1906 

Glutona     

22.1 

11.8 

58.5 

54. 91 

429 

1906 

Glutosac  Butter  Wafers 

27.6 

12.9 

49.4 

41.2i 

424 

1906 

Glutosac  Rusks 

36.5 

3.8 

51.6 

42. 5> 

387 

1906 

Wafers,  Plain 

29.4 

9.6 

49.9 

41. 61 

404 

1906 

Zwieback 

32.5 

6.9 

49.3 

40. 91 

389 

1913 

No.  1  Proto  Puffs       .... 

76.3 

2.9 

10.7 

4.3 

374 

1913 

No.  2  Proto  Puffs      .... 

56.6 

2.1 

30.7 

19.0 

368 

1906 

Protosac  Rusks 

40.9 

2.0 

48.7 

43. 91 

376 

1913 

Protosoy  Diabetic  Wafers    . 

43.1 

24.9 

21.2 

4.7 

481 

1906 

Salvia  Sticks 

39.2 

20.8 

2.4 

18. 71 

440 

1914 

Gluten  Nuggets    .      .      .  -  . 

31.7 

14.3 

45.7 

34.9 

438 

1914 

Gluten  Butter  Wafers     . 

31.1 

13.9 

47.0 

38.9 

438 

1914 

Gluten  Rusks 

39.3 

3.4 

47.0 

33.6 

376 

1914 

Gluten  Wafers,  Plain 

42.6 

1.7 

44.3 

29.6 

363 

Gluten  Zwieback        .... 

36.4 

7.7 

46.6 

32.5 

401 

1914 

Manana  Gluten  Breakfast  Food 

42.6 

2.0 

43.6 

29.9 

363 

1914 

No.  1  Proto  Puffs       .... 

72.3 

2.8 

13.0 

9.2 

366 

1914 

No.  2  Proto  Puffs      .... 

58.8 

2.1 

27.0 

20.7 

362 

1914 

Protosac  Rusks 

39.7 

3.0 

46.7 

35.9 

373 

1914 

Protosoy  Diabetic  Wafers    . 

37.1 

23.5 

29.3 

14.4 

477 

1914 

Salvia  Almond  Sticks 

22.3 

29.9 

41.0 

28.3 

523 

1913 

Heinz  Food  Co.,  Chicago: 

Gluten  Biscuits 

12.8 

18.3 

57.7 

21.4 

447 

1914 

Heudebert,  Paris: 
Pain   d'Aleurone   pour    Diabet- 

iques       

76.1 

1.5 

9.2 

4.2 

354 

1914 

Pain  de  Gluten  pour  Diabetiques 

80.7 

0.8 

6.5 

3.4 

356 

1914 

Pain    de    "Essential"    en    Bis- 

cottes     

26.4 

1.2 

62.2 

49.9 

365 

1906 

Jireh    Diabetic    Food    Co.,    New 
York: 

Diabetic  Biscuits       .... 

14.8 

3.7 

72.3 

65. 41 

382 

1906 

Diabetic  Rusks 

14.6 

5.0 

67.7 

374 

1913 

Diatetic  Biscuits        .... 

13.2 

7.4 

70.8 

49.6 

403 

1913 

Diatetic  Rusks 

14.9 

8.7 

68.0 

47.0 

410 

1906 

Wheat  Nuts 

19.0 

15.6 

54.5 

50.  I1 

434 

1906 

Johnson     Educator     Food     Co., 
Boston: 

Almond  Biscuits 

29.0 

8.8 

54.3 

50. 01 

412 

1906 

Diabetic  Biscuits        .... 

25.3 

7.5 

59.0 

54. 9l 

405 

1906 

Educator    Crackers,     Greseni 

Gluten 

23.0 

4.6 

63.1 

57.91 

386 

1  Determined  by  the  diastase  method,  without  previous  washing 
water,  and  calculated  as  starch. 


with 


DIET  TABLES 


161 


So-called  Diabetic  Prepara- 
tions. 

a 
a  a 

O  O. 

o 

-  ffl 
fa 

o 

1.1 

O 

CD  m 

T3ftC 

3.2© 

«  °~ 

O 

Hard  Breads,  etc. — Continued. 

Johnson     Educator     Food     Co., 

Boston: 

1913 

Educator   Gluten  Bread    Sticks 

35.9 

7.2 

45.8 

37.5 

392 

1911 

Gluten  Cookies 

26.4 

16.0 

49.8 

37.8 

449 

1906 

Gluten  Rusk,  Greseni  Gluten    . 

22.1 

0.3 

68.1 

63. 31 

364 

1906 

Gluten  Wafers 

30.3 

0.4 

61.2 

57. 01 

370 

1906 

Glutine,  Greseni  Gluten 

21.9 

0.8 

67.7 

63.  I1 

366 

1912 

The    Kellogg    Food    Co.,    Battle 
Creek,  Mich.: 

Avena-Gluten  Biscuit 

21.4 

12.7 

55.5 

41.1 

422 

1913 

Potato  Gluten  Biscuit     .      .      . 

41.5 

0.5 

48.0 

39.5 

363 

1909 

Pure  Gluten  Biscuit  .... 

48.3 

3.3 

39.1 

379 

1913 

Taro-Gluten  Biscuit- 

31.3 

0.5 

57.7 

48.2 

361 

1913 

40  per  cent.  Gluten  Biscuit 

37.2 

0.8 

53.2 

45.0 

369 

1912 

SO  per  cent.  Gluten  Biscuit 

82.4 

0.9 

4.4 

4.7 

355 

1913 

Eugene  Loeb,  New  York: 

Gluten  Luft  Bread    .... 

27.9 

9.2 

54.2 

44.1 

411 

1914 

Gluten  Luft  Bread     .... 

52.4 

13.2 

26.0 

22.9 

433 

1914 

Chocolate  Almond  Bars 

16.3 

41.0 

31.8 

5.7 

561 

1914 

Diabetic  Almond  Macaroons     . 

46.5 

37.7 

8.0 

0.6 

558 

1914 

Diabetic  Bread  Sticks     . 

50.4 

3.4 

34.5 

24.6 

371 

1914 

Diabetic  Chocolates 

14.9 

51.4 

23.0 

6.9 

614 

1914 

Diabetic  Lady  Fingers    . 

56.6 

28.3 

6.0 

1.8 

505 

1914 

Diabetic  Sponge  Cookies 

54.7 

30.1 

5.0 

1.2 

510 

1913 

Pure  Gluten  Food  Co.,  New  York: 

Gum  Gluten  Biscuit  Crisps 

42.9 

0.7 

48.5 

39.3 

372 

1913 

G.  Van  Abbott  &  Sons,  London: 

Caraway  Biscuits  for  Diabetics 

35 . 6 

37.5 

15.9 

8.6 

544 

1913 

Diabetic    Rusks    for    Diabetics 

70.9 

0.8 

16.0 

12.6 

355 

1913 

Euthenia  Biscuits      ... 

_35.8 

40.7 

13.2 

6.9 

562 

1913 

Gluten  Biscottes  or  Rolls 

51.6 

2.3 

33.0 

29.8 

359 

1913 

Gluten  Bread  or  Slices    . 

54.1 

2.2 

30.9 

27.4 

361 

1913 

Gluten  Butter  Biscuits  for  Dia- 

betics       

44.1 

33.2 

12.7 

9.0 

526 

1913 

Ginger    Biscuits    for    Diabetics 

34.6 

39.4 

16.7 

10.9 

560 

1913 

Midolia  Biscuits 

17.6 

36.4 

31.6 

13.4 

524 

1913 

Walnut   Biscuits   for    Diabetics 

20.9 

57.2 

12.3 

trace 

648 

1913 

Waukesha  Health  Products  Co., 
Waukesha,        Wis. :        Hepco 

Dodgers 

41.6 

21.3 

20.7 

trace 

441 

1913 

Callard,  Stewart  &  Watt,  London 

Casoid  Chocolate  Almonds 

22.3 

51.8 

16.1 

trace 

620 

1  Determined  by  the  diastase  method,  without    previous   washing  with 
water,  and  calculated  as  starch. 
11 


162  DIABETIC  MENU  AND  FOOD  VALUES 

Wines:1  Dry. 


Grams   reduc- 
ing sugars,  per 
100  c.c. 


California,  red,  Bordeaux  or  Claret     .  (range  0.04-  0.63)  0.16 

"    Burgundy  ....  (range  0.03-  0.42)  0.15 

"    Zinfandel    ....  (range  0.03-  0.35)  0.15 

"          white,  Rhine      ....  (range  0 .  06-  0 .  63)  0 .  15 

"      Burgundy     .      .       .  (range  0.10-  0.45)  0.23 

"      Sauterne       .      .      .  (range  0.07-  3.57)  0.64 

French,  red    (range  0.11-0.84)  0.23 

white (range  0.65-  1.02)  0.84 

German,  white (range  0.09-1.96)  0.20 

Hungarian,  white (range  0.04-0. 86)  0.25 

Italian,  red (range  0.02-2.70)  0.16 

"       white (range  0.02-  2.15)  0.19 

North  Carolina (range  0.08-1.75)  0.49 

Ohio (range  0.07-  1.54)  0.31 

Portuguese,  red (range  0.01-  1.21)  0.16 

white (range  0.10-  1.19)  0.32 

Rhine,  red (range  0.06-0.27)  0.13 

"      white (range  0.02-  1.02)  0.18 

Spanish,  red (range  0.19-0.54)  0.35 

white (range  0.27-  0.62)  0.42 

Sparking,  French  and  German       .      .  (range  0.13-  1.95)  0.53 

Swiss,  red (range  0.10-0.27)  0.13 

"      white (range  0.08-  0.38)  0.10 

Virginia (range  0.06-  1.23)  0.16 


Wines:  Sweet. 

California  Port (range  0.23-13.56)  4.76 

Madeira  and  Sherry       .      .  (range  0.12-17.21)  5.38 

French      (range  0.73-12.40)  5.38 

German (range  0.64-12.13)  4.60 

Madeira (range  2.48-  3.88)  2.95 

Malaga (range  12.50-25.20)  18.32 

Marsala (range  2.67-  8.24)  3.25 

Port (range  3.76-  8.17)  6.04 

Rhine (range  1.82-10.69)  6.35 

Sherry      (range  0.52-  4.80)  2.54 

Sparkling,  American '(range  6.51-12.02)  8.28 

French  and  German      .      .  (range  8.00-18.50)  10.92 

Tokay,  true   (range  1.86-20.50)  12.62 

"      commercial (range  2.70-40.70)  19.80 

Vermouth (range  3.47-14.39)  9.46 

1  Wines  contain  approximately  10  per  cent,  alcohol. 


DIET  TABLES  163 

Wines:  Especially  Low  in  Carbohydrate. 

Alcohol  by  Carbo- 

volume  hydrate, 

Manufacturer  or  Agent  and  Brand.  percent.  percent.1 

Alfonso  &  Hipolito: 

Sancho  Vinos  de  Jerez  Amontillado  Don  Quixote 

(Wm.  J.  Sheehan  Co.,  New  Haven,  Agents)  20.60  1.23 

Brotherhood  Wine  Co.,  New  York  City: 

Sunnyside  Claret 11.87  0.10 

Riesling 12.37  0.34 

Vin-Crest  Brut ...  12.24  1.66 

California  Wine  Association,  New  York  City: 

Riesling 11.31  0.10 

Zinfandel      ....  11.62  0.16 

Calwa  Distributing  Co.,  New  York  City:2 

"Calwa"  Brand  Greystone  (Light  Hock  Type)3    11.81  0.19 

"Calwa"  Brand  La  Loma  (Burgundy  Type)2  .  11.27  0.14 

"Calwa"  Brand  Vine  Cliff  (Riesling)2    .      .      .  10.90  0.17 

' '  Calwa ' '  Brand  Winehaven  (Table  Claret)2     .  1 1 .  46  0.14 

H.  T.  Dewey  &  Sons  Co.,  New  York  City: 

Ives  Claret 12.53  0.24 

Moselle  Type    ..." 8.37  0.14 

Old  Burgundy  Type 11.14  0.27 

Ruby  Claret      .      .      :  13.03  0.27 

Pedro  Domecq's  Manzanilla  Sherry3  .  .      .      .  20.86  0.32 

Empire  State  Wine  Co.,  Penn  Yan,  N.  Y. : 

Dry  Catawba 12.80  0.15 

State  Seal  Champagne 12.39  1.51 

Los  Angeles  Co.,  Boston,  Mass: 

California  Chasselas 12.12  2.97 

California  Chasselas 11.68  2.99 

California  Gutedel 11.87  0.79 

California  Gutedel 11.56  0.19 

Monticello  Wine  Co.,  Charlottesville,  Va.: 

Extra  V.  Claret 12.80  0.25 

Norton's  Virginia 12.57  0.37 

Virginia  Claret 12.54  0.20 

Virginia  Hock _     .      .      .  12.60  0.22 

A.  Pierlot  &  Co.,  Bouzy,  Rheims: 

Champagne  Vin  Nature  sans  Sucre  .      .      .      .  11.97  0.36 

Pleasant  Valley  Wine  Co.,  Rheims,  N.  Y.: 

Claret 11.22  0.29 

Dry  Catawba 12.02  0.18 

Great  Western  Extra  Dry 12.33  4.36 

William  J.  Sheehan  Co.,  New  Haven,  Agents: 

California  Cabernet 11.49  0.31 

California  Hock 11.21  0.14 

California  Riesling 11.15  0.14 

California  Zinfandel 11.32  0.16 

Urbana  Wine  Co.,  TJrbana,  N.  Y. : 

Gold  Seal  Brut 12.14  2.30 

Gold  Seal  Absolutely  Dry  12.65  0.54 

Gold  Sparkling  Red,  Special  Dry      .      .      .      .  11.26  2.86 

Gold  Sparkling  Red,  Absolutely  Dry      .      .      .  11.98  0.29 

1  Grams  reducing  sugars  per  100  c.c. 

2  Sold  by  M.  Zunder  &  Sons,  New  Haven,  Conn. 
»  Sold  by  Chris.  Xander,  Washington,  D.  C. 


164  DIABETIC  MENU  AND  FOOD  VALUES 


Other  Alcoholic  Beverages. 

Brandy,  gin,  rum,  whisky 01 

Absinth Trace 

Angostura 4.2 

Beer 4.5 

Weiss  bier 4.6 

Ale 5.1 

Porter  or  Stout 7.0 

Malt  extract,  commercial      .       .       .  10.6 

Curacao 25.5 

Creme  de  men  the 27.7 

Kummel 31.2 

Benedictine 32.6 

Anisette 34.4 

Chartreuse 34.4 

Maraschino 52.3 

Malt  extract,  true 71.3 

1  Grams  reducing  sugars  per  100  c.c. 


PART  IV. 

SELECTED  LABORATORY  TESTS  USEFUL  IN 
MODERN  DIABETIC  TREATMENT. 


CHAPTER   I. 

THE  EXAMINATION  OF  THE  URINE,  BLOOD 
AND  EXPIRED  AIR. 

An  early  diagnosis  in  diabetes  is  as  important  as  in  tuber- 
culosis. The  disease  usually  begins  insidiously,  and  its 
prompt  detection  depends  upon  the  routine  examination  of 
the  urine  of  all  patients  rather  than  upon  the  examination 
of  the  urines  of  patients  who  present  symptoms  of  the  disease. 
General  practitioners  should  teach  their  patients,  as  a  matter 
of  routine,  to  have  their  own  urines  and  those  in  their  families 
examined  each  birthday.  This  is  not  fantastic.  It  is  simply 
a  part  of  the  movement  to  have  each  member  of  the  com- 
munity undergo  a  physical  examination  each  year. 

EXAMINATION  OF  THE  URINE 

Examination  of  the  urine  should  cost  the  patient  little. 
Formerly  I  deprecated  the  routine  examinations  made  in 
drug  stores,  but  now  I  welcome  them.  The  druggist  is  a 
trained  chemist.  He  is  constantly  doing  quantitative  work, 
and  it  is  far  easier  and  cheaper  for  him  to  examine  a  urine 
than  for  a  doctor.  Druggists  will  undoubtedly  undertake 
such  work  with  satisfaction.  It  will  be  an  agreeable  relief 
from  the  many  activities  in  a  drug  store  which  have  nothing 
to  do  with  the  profession  of  a  pharmacologist. 


1GG        SELECTED  LABORATORY  TESTS 

The  examination  of  the  urine  of  the  diabetic  patient  is 
usually  a  simple  matter.  It  comprises  a  statement  indicating 
the  volume  in  twenty-four  hours,  specific  gravity,  reaction, 
presence  or  absence  of  albumin,  sugar  and  diacetic  acid. 
Frequently  the  ammonia,  salt  (sodium  chloride),  acetone  and 
nitrogen  are  determined  and  the  urinary  sediment  submitted 
to  microscope   study. 

Although  diabetic  patients  can  test  their  own  urines  for 
sugar  and  almost  invariably  arc  warranted  in  relying  upon 
the  result  of  their  examination,  they  should  not  feel  that  they 
are  expert  analysts.  More  than  once  patients  have  arrived 
at  erroneous  conclusions,  in  part  due  to  the  preparation  of 
chemical  reagents  employed.  I  believe  it  is  therefore  safer 
for  all  diabetic  patients  to  send  their  urines  once  a  month  to 
their  physician,  for  the  simple  tests  for  volume,  color,  reaction, 
specific  gravity,  albumin  and  sugar.  Such  an  examination 
can  be  made  by  a  physician  within  fifteen  minutes.  A  quanti- 
tative examination  for  sugar  would  require  an  individual,  not 
daily  accustomed  to  it,  not  far  from  half  an  hour  or  more. 

The  Collection  of  the  Twenty-four-hour  Quantity  of  Urine.— 
To  collect  the  twenty-four-hour  quantity  of  urine,  discard 
that  voided  at  7  a.m.  and  then  save  in  a  cool  place  all  urine 
passed  thereafter  up  to  and  including  that  obtained  at  7  a.m. 
the  next  morning. 

Reaction. — The  normal  urine  is  acid.  Urine  voided  after 
a  meal  rich  in  vegetables  and  fruits  is  frequently  alkaline, 
due  to  the  alkaline  salts  which  they  contain.  Therefore  the 
report  that  the  urine  is  acid  does  not  imply  in  the  slightest 
degree  that  a  patient  has  acid  poisoning.  (For  detection  of 
acid  poisoning,  see  Tests  for  Diacetic  Acid  and  Ammonia, 
pp.  17G  and  177.) 

Specific  Gravity. — The  specific  gravity  of  the  urine  will  be 
best  understood  if  it  is  recalled  that  the  specific  gravity  of 
water  is  considered  to  be  1000.  Normal  urine  has  a  specific 
gravity,  on  account  of  the  solids  contained  in  it,  of  about  1015 
to  1020.  Normal  urine  if  concentrated  would  have  a  higher 
specific  gravity,  and  if  dilute  it  would  be  lower.  The  specific 
gravity  of  the  urine  in  diabetes  varies  chiefly  with  the 
percentage  of  sugar  which  it  contains.     It  frequently  is 


EXAMINATION  OF  URINE,  BLOOD,  EXPIRED  AIR     167 

above  1020  and  may  be  above  1040,  but  I  have  known  sugar 
to  be  present  in  the  urine  when  the  specific  gravity  was  as 
low  as  1007. 

Albumin. — Two  tests  are  usually  employed,  the  one  in 
confirmation  of  the  other. 

1.  Nitric  Acid  Test. — To  5  c.c.  of  filtered  urine  add  one- 
third  the  quantity  of  nitric  acid  by  pouring  it  down  the  side 
of  the  glass  so  that  it  underlies  the  urine.  A  white  precipitate 
forms  in  the  urine  at  the  junction  of  the  two  fluids.  A  pre- 
cipitate higher  in  the  urine  may  be  due  to  urates.  Bile  or 
urinary  coloring  matters  may  give  a  color  to  the  urine  or 
precipitate  at  the  junction  of  the  fluids. 

2.  Heat  Test. — Pour  10  c.c.  of  filtered  urine  into  a  test-tube 
and  boil  the  upper  half  of  the  fluid.  Add  one  or  two  drops 
(not  more)  of  ordinary  (36  per  cent.)  acetic  acid  and  boil 
again.  A  precipitate  appearing  on  boiling  which  persists 
after  the  addition  of  the  acid,  or  appearing  on  the  second 
boiling,  is  albumin;  one  disappearing  with  the  acid  is  phos- 
phates.   The  test  may  fail  with  an  excess  of  acid. 

Sugar. — Sugar  is  absent  from  the  urine  of  carefully  treated 
diabetics.  If  present  it  can  be  readily  demonstrated  if  it 
amounts  to  as  little  as  0.05  per  cent.,  and  it  may  rise  to  as 
high  as  9  or  10  per  cent,  when  the  diabetic  diet  is  not  followed. 
Most  untreated  cases  show  between  2  and  6  per  cent,  of 
sugar.  The  total  quantity  of  sugar  in  the  urine  in  the  twenty- 
four  hours  is  easily  estimated  by  multiplying  the  percentage 
of  sugar  which  the  urine  contains  by  the  total  amount  of 
urine  voided.  Thus,  if  the  total -quantity  of  urine  is  3  liters 
(3000  c.c,  a  little  more  than  3  quarts,  which  would  equal 
2838  c.c),  and  the  percentage  of  sugar  is  4,  the  amount  of 
sugar  in  the  urine  would  be  (3000  X  0.04)  120  grams,  that  is, 
about  4  ounces  or  \  pound.  It  is  not  very  often  that  one 
finds  more  than  1  pound  of  sugar  excreted  in  the  urine  during 
twenty-four  hours.  The  food  value  of  the  sugar  lost,  if  only 
120  grams,  is  considerable.  Each  gram  of  sugar  is  the 
equivalent  of  4  calories,  and  the  total  would  amount  to  480 
calories  in  a  day,  wThich  is  approximately  one-fourth  of  the 
total  food  value  required  by  an  individual,  with  a  quiet 
occupation,  who  weighs  60  kilograms  (132  pounds) .   Thus  it  is 


168        SELECTED  LABORATORY  TESTS 

evident  that  4  untreated  diabetics,  even  though  the  disease 
is  of  very  moderate  severity,  provided  they  eat  enough  to 
make  up  the  loss,  will  waste  in  a  day  enough  food  to  supply 
the  needs  of  a  normal  individual  of  equal  weight  for  the  same 
space  of  time. 

Tests  for  Sugar. — Qualitative  Tests. — Many  tests  for  sugar 
in  the  urine  are  employed.  At  present  I  use  the  Benedict 
test1  most.  The  Benedict  solution  employed  has  the  advan- 
tage of  not  decomposing  even  after  months.  Druggists  occa- 
sionally find  difficulty  in  making  it,  and  on  three  occasions 
my  patients  have  been  sold  unreliable  solutions.  The  quali- 
tative Benedict  solution  is  made  as  follows: 

Grams  or  c.c. 

Copper  sulphate  (pure  crystallized) 17.3 

Sodium  or  potassium  citrate 173.0 

Sodium  carbonate  (crystallized)    (one-half  the  weight  of 

the  anhydrous  salt  may  be  used) 200 . 0 

Distilled  water  to  make 1000 . 0 

The  citrate  and  carbonate  are  dissolved  together  (with  the 
aid  of  heat)  in  about  700  c.c.  of  water.  The  mixture  is  then 
poured  (through  a  filter  if  necessary)  into  a  larger  beaker  or 
casserole.  The  copper  sulphate  (which  should  be  dissolved 
separately  in  about  100  c.c.  of  water)  is  then  poured  slowly 
into  the  first  solution,  with  constant  stirring.  The  mixture 
is  then  cooled  and  diluted  to  one  liter.  This  solution  keeps 
indefinitely. 

Case  No.  632  has  written  out  the  rules  for  the  test,  with  his 
customary  military  directness  and  precision: 

Benedict's  solution  is  used  for  testing  the  urine  for  sugar 
as  follows:  To  about  5  c.c.  (one  large  teaspoonful)  of  the 
solution  add  8  drops  of  urine;  the  test  may  then  be  continued 
in  either  of  the  two  following  ways: 

1.  Boil  the  mixture  of  the  solution  and  urine  for  three 
minutes  and  set  aside  to  cool  to  the  temperature  of  the  room. 

2.  Place  the. tube  containing  the  mixture  of  the  solution 
and  urine  in  bubbling,  boiling  water,  where  it  must  remain, 
with  the  water  actually  boiling,  for  five  minutes. 

In  either  case  if  the  solution  remains  clear  the  urine  being 
tested  is  sugar-free;  if  a  heavy  greenish  precipitate  forms  it 

1  Benedict,  S.  R.:     Jour.  Am.  Med.  Assn.,  1911,  lvii,  p.  1193. 


EXAMINATION  OF  URINE,  BLOOD,  EXPIRED  AIR     169 

usually  means  there  is  a  trace  of  sugar;  the  appearance  of  a 
yellow  sediment  indicates  the  presence  of  a  few  tenths  per 
cent,  of  sugar  in  the  urine,  and  a  red  sediment  more. 

Benedict's  original  description  of  the  test  is  as  follows: 
Five  cubic  centimeters,  a  trifle  over  one  teaspoonful,  of  the 
Benedict  solution,  are  placed  in  a  test-tube  and  8  to  10  drops 
(not  more)  of  the  urine  to  be  examined  are  added.  The  mix- 
ture is  then  heated  to  vigorous  boiling,  kept  at  this  tempera- 
ture for  three  minutes,  and  allowed  to  cool  spontaneously. 
In  the  presence  of  glucose  the  entire  body  of  the  solution  will 
be  filled  with  a  precipitate,  wrhich  may  be  greenish,  yellow 
or  red  in  tinge  according  to  whether  the  amount  of  sugar  is 
slight  or  considerable.  If  the  quantity  of  glucose  be  lowr 
(under  0.3  per  cent.)  the  precipitate  forms  only  on  cooling. 
If  no  sugar  be  present,  the  solution  either  remains  perfectly 
clear,  or  shows  a  faint  turbidity  that  is  blue  in  color,  and 
consists  of  precipitated  urates.  The  chief  points  to  be  remem- 
bered in  the  use  of  the  reagent  are  (1)  the  addition  of  a  small 
quantity  of  urine  (8  to  10  drops)  to  5  c.c.  of  the  reagent,  this 
being  desired  not  because  larger  amounts  of  normal  urine 
would  cause  reduction  of  the  reagent,  but  because  more 
delicate  results  are  obtained  by  this  procedure;  (2)  vigorous 
boiling  of  the  solution  after  addition  of  the  urine,  and  then 
allowing  the  mixture  to  cool  spontaneously,  and  (3)  if  sugar 
be  present  the  solution  (either  before  or  after  cooling)  will  be 
filled  from  top  to  bottom  with  a  ^precipitate,  so  that  the 
mixture  becomes  opaque. 

Benedict  (personal  communication)  states  that  the  test  as 
performed  above  will  detect  glucose  in  as  low  concentration 
as  0.01  to  0.02  per  cent,  provided  the  urine  is  of  low  dilution. 

Fehling's  Test. — The  solutions  required  are  made  up  as 
follows:  Dissolve  34.64  gm.  pure  CuS04  in  water  and  make 
up  to  500  c.c.  Dissolve  173  gm.  Rochelle  salt  and  60  gm. 
sodium  hydrate  each  in  200  c.c.  water  and  mix,  and  then  make 
up  also  to  500  c.c. ;  5  c.c.  of  each  solution  are  used  for  the  test. 

In  performing  the  test,  3  to  5  c.c.  of  equal  quantities  of  the 
copper  solution  and  the  alkaline  solution  are  mixed  in  a  test- 
tube  and  thoroughly  boiled.  If  no  reduction  takes  place 
one-half  as  much  urine  as  the  reagent  employed  is  then  added 


170        SELECTED  LABORATORY  TESTS 

and  the  whole  boiled  vigorously  again.  A  yellow  or  red 
precipitate  indicates  the  presence  of  sugar;  a  greenish  pre- 
cipitate may  or  may  not  indicate  sugar.  Occasionally  sub- 
stances in  the  urine  other  than  sugar  reduce  the  copper  upon 
prolonged  boiling,  but  this  is  so  exceptional  that  I  consider 
it  far  safer  to  boil  the  solution  a  second  time,  and  when  in 
doubt,  to  repeat  the  test  without  boiling. 

Quantitative  Tests. — All  quantitative  tests  for  glucose  in 
the  urine  are  as  unsatisfactory  as  the  qualitative  tests  are 
satisfactory.  It  is  one  of  the  chief  advantages  of  modern 
treatment  that  the  need  for  these  tests  is  nearly  abolished.  It 
will  be  one  of  the  disadvantages  of  modern  treatment  if  we 
introduce  a  multiplicity  of  new  tests  in  diabetes.  The 
simplification  of  the  treatment  of  diabetes  means  everything 
to  the  practitioner  and  patient.  The  simplest  quantitative 
test  for  sugar  for  physicians  who  do  not  devote  unusual 
attention  to  diabetes  is  the  fermentation  test. 

Fermentation  Test. — To  100  c.c.  of  urine  of  known 
specific  gravity,  one-fourth  of  a  fresh  yeast  cake,  thoroughly 
broken  up,  is  added  and  the  whole  is  set  away  at  a  temperature 
of  85°  to  95°  F.  Twenty-four  hours  later  the  urine  is  tested 
with  Fehling's  or  Benedict's  solutions.  If  a  reduction  is 
obtained  it  is  set  aside  for  further  fermentation.  Complete 
fermentation  having  been  proved,  the  specific  gravity  is 
taken  after  the  urine  has  acquired  its  original  (room)  tem- 
perature. The  difference  in  specific  gravity  multiplied  by 
0.23  gives  the  percentage.  In  the  performance  of  the  fermen- 
tation test  for  sugar  a  few  crystals  of  tartaric  acid  should  be 
added  whenever  the  urine  is  alkaline.  If  the  temperature  of 
the  urine  (room)  is  76°  F.  when  the  specific  gravity  is  taken 
at  the  beginning  and  end  of  the  test  the  result  will  be  still 
more  accurate. 

Benedict's  Test. — The  easiest  method  with  which  I  am  ac- 
quainted for  performing  the  quantitative  Benedict  test  is  that 
employed  by  Miss  Evelyn  Warren,  my  laboratory  assistant. 

Quantitative  Benedict  Solution. 

The  quantitative  Benedict  solution  is  different  from  the 
qualitative.     Mistakes  often  occur  from  this  solution  being 


EXAMINATION  OF  URINE,  BLOOD,  EXPIRED  AIR     171 

used  for  the  qualitative  test  for  sugar,  for  which  purpose  it 
is  valueless.  The  quantitative  Benedict  solution  is  given  on 
page  173. 


Fig.   16.— Apparatus  required  for  a  simplified,  quantitative  Benedict  test. 


172        SELECTED  LABORATORY  TESTS 


Articles  Required. 

Ten  cubic  centimeter  graduated  pipette;  small  white 
enamelware  dish,  3  inches  across,  2  inches  deep;  sodium 
carbonate;  talcum. 

The  test  can  be  performed  by  the  aid  of  a  kitchen  gas 
burner.  If  the  gas  burner  is  not  a  small  one  and  so  flares  up 
around  the  edges  of  the  dish,  put  an  asbestos  plate  or  simply 
an  iron  cover  over  it. 

Performance  of  Test. 

1.  Place  5  c.c.  of  the  quantitative  Benedict  solution  in 
the  dish. 

2.  Add  less  than  one-fourth  teaspoonful  of  sodium  car- 
bonate. 

3.  Add  one-half  as  much  talcum. 

4.  Add  about  10  c.c.  water. 

5.  Dilute  1  part  urine  with  9  parts  of  water  unless  the 
quantity  of  sugar  is  low.  (A  low  per  cent,  of  sugar  is  shown 
by  the  qualitative  Benedict  test  turning  green  instead  of 
yellow.  With  small  quantities  of  sugar,  it  is  unnecessary  to 
dilute  the  urine.) 

G.  Bring  the  contents  of  the  dish  to  boiling,  maintain  in 
this  condition  and  then  add,  drop  by  drop,  the  urine  from  the 
graduated  pipette  until  the  blue  color  has  entirely  disap- 
peared. Upon  the  first  trial  too  much  may  be  added,  and 
therefore,  having  noted  the  approximate  quantity  of  urine 
required  to  reach  the  end-point,  invariably  repeat  the  test  as 
a  control. 

Calculation. 

Five  cubic  centimeters  of  the  Benedict  quantitative  copper 
solution  are  reduced  by  0.01  gram  glucose.  Consequently, 
the  quantity  of  undiluted  urine  required  to  reduce  the  5  c.c. 
Benedict  solution  contains  0.01   gram  glucose. 

o.oi 

—  X  100  =  per  cent.  x  =  c.c.  of  undiluted  urine. 

x 


EXAMINATION  OF  URINE,  BLOOD,  EXPIRED  AIR        173 

Example. — Fifteen  hundred  cubic  centimeters  urine  in 
twenty-four  hours.  Five  cubic  centimeters  used  to  reduce 
(decolorize)  the  Benedict  solution. 

— : —  X  100  =  0 . 2  per  cent. 
5 
1500  X  0.002  (0.2  per  cent.)   =  3  grams  sugar  in  twenty-four  hours. 

Example. — If  the  urine  had  been  diluted  with  9  parts  water 
—in  other  words,  10  times — the  calculation  would  be: 

5  c.c.  diluted  urine  =  0.5  c.c.  actual  urine. 

-1— -    X  100  =  2  per  cent. 
0.5 

1500  X  0.02  (2  per  cent.)    =  30  grams  sugar  in  twenty-four  hours. 

For  convenience  in  the  laboratory,  instead  of  working  out 
the  percentages  of  sugar  in  the  urine  by  the  above  formula, 
we  use  the  accompanying  scale,  shown  in  Table  32. 

The  method  as  originally  described  by  Benedict1  is  as 
follows:  "Like  Fehling's  quantitative  process  the  method  is 
based  on  the  fact  that  in  alkaline  solution  a  given  quantity 
of  glucose  reduces  a  definite  amount  of  copper,  thus  decoloriz- 
ing a  certain  amount  of  copper  solution.  The  copper  is, 
however,  precipitated  as  cuprous  sulphocyanate,  a  snow- 
white  compound,  which  is  an  aid  to  accurate  observation 
of  the  disappearance  of  the  last  trace  of  color.  The  solu- 
tion for  quantitative  work,  which  keeps  indefinitely,  has  the 
following  composition : 

Pure  crystallized  copper  sulphate,  18  grams. 

Crystallized  sodium  carbonate,  200  grams  (or  100  grams 
of  the  anhydrous  salt) . 

Sodium  or  potassium  citrate,  200  grams. 

Potassium  sulphocyanide,  125  grams. 

Five  per  cent,  potassium  ferrocyanide  solution,  5  c.c. 

Distilled  water  to  make  a  total  volume  of  1000  c.c." 

i  Benedict,  S.  R.:     Loc.  cit.,  p.  168. 


174 


SELECTED  LABORATORY  TESTS 


Table  32. — Per  Cent,  of  Sugar  by  Benedict  Method. 


Urine,  c.c.  used. 

Sugar,  per  cent. 

Urine,  c.c.  used. 

Sugar,  per  c 

0.1 

10.0 

3.6 

0.28 

0.2 

5.0 

:;.7 

0.27 

0.3 

3.3 

3.8 

0.26 

0.4 

2.5 

:;.!i 

0.26 

0.5 

2.0 

4.0 

0.25 

0.6 

1.7 

4.1 

0.24 

0.7 

1.4 

4.2 

0.24 

0.8 

1.3 

4.3 

0 .  23 

0.9 

1.1 

4.4 

0.23 

1.0 

1.0 

4.5 

0.22 

1.1 

0.91 

4.6 

0.22 

1.2 

0.83 

4.7 

0.21 

1.3 

0.77 

4.S 

0.21 

1.4 

0.71 

4.9 

0.20 

1.5 

0.67 

5.0 

0.20 

1.6 

0.63 

5.1 

0.20 

1.7 

0.58 

1.8 

0.55 

5.2 

0.19 

1.9 

0.53 

5.3 

0.19 

2.0 

0.50 

5.4 

0.19 

2.1 

0.48 

5.5 

0.18 

2.2 

0.45 

5.6 

0.18 

2.3 

0.43 

5.7 

0.18 

2.4 

0.42 

5.8 

0.17 

2.5 

0.40 

5.9 

0.17 

2.6 

0.38 

6.0 

0.17 

2.7 

0.37 

6.1-  6 

.4 

0.16 

2.8 

0.36 

6.5-  6 

.9 

0.15 

2.9 

0.34 

7.0-  7 

.4 

0.14 

3.0 

0.33 

7.5-  7 

,9 

0.13 

3.1 

0.32 

8.0-  8 

.7 

0.12 

3.2 

0.31 

8.8-  9 

.5 

0.11 

3.3 

0.30 

9.0-10 

.0 

0.10 

3.4 

0.29 

3.5 

0.29 

"  With  the  aid  of  heat  dissolve  the  carbonate,  citrate,  and 
sulphocyanide  in  enough  water  to  make  about  800  c.c.  of  the 
mixture  and  filter  if  necessary.  Dissolve  the  copper  sulphate 
separately  in  about  100  c.c.  of  water  and  pour  the  solution 
into  the  other  liquid,  with  constant  stirring.  Add  the  ferro- 
cyanide  solution,  cool  and  dilute  to  exactly  one  liter.  Of  the 
various  constituents  the  copper  salt  only  need  be  weighed  with 
exactness.  Twenty-five  cubic  centimeters  of  the  reagent  are 
reduced  by  50  mg.  (0.050  gram)  of  glucose." 

The  procedure  for  the  estimation  is  as  follows:  "The 


EXAMINATION  OF  URINE,  BLOOD,  EXPIRED  AIR    175 

urine,  10  c.c.  of  which  should  be  diluted  with  water  to  100  c.c. 
(unless  the  sugar  content  is  believed  to  be  low),  is  poured  into 
a  50  c.c.  burette  up  to  the  zero  mark.  Twenty-five  cubic 
centimeters  of  the  reagent  are  measured  with  a  pipette  into  a 
porcelain  evaporating  dish  (10  to  15  cm.  in  diameter),  10 
to  20  grams  of  crystallized  sodium  carbonate  (or  one-half  the 
weight  of  the  anhydrous  salt)  are  added  together  with  a  small 
quantity  of  powdered  pumice  stone  or  talcum,  and  the 
mixture  heated  to  boiling  over  a  free  flame  until  the  car- 
bonate has  entirely  dissolved.  The  diluted  urine  is  now  run 
in  from  the  burette,  rather  rapidly,  until  a  chalk-white  pre- 
cipitate forms  and  the  blue  color  of  the  mixture  begins  to 
lessen  perceptibly,  after  which  the  solution  from  the  burette 
must  be  run  in,  a  few  drops  at  a  time,  until  the  disappearance 
of  the  last  trace  of  blue  color  which  marks  the  end-point. 
The  solution  must  be  kept  vigorously  boiling  throughout  the 
entire  titration." 

If  the  mixture  becomes  too  concentrated  during  the  process, 
water  may  be  added  from  time  to  time  to  replace  the  volume 
lost  by  evaporation;  however,  too  much  emphasis  cannot  be 
placed  upon  the  fact  that  the  solution  should  never  be  diluted 
before  or  during  the  process  to  more  than  the  original  25  c.c. 
Moreover,  it  will  be  found  that  in  titrating  concentrated 
urines,  or  urines  with  small  amounts  of  sugar,  a  muddy 
brown  or  greenish  color  appears  and  obscures  the  end-point 
entirely.  Should  this  be  the  case  the  addition  of  about  10 
grams  of  calcium  carbonate  does  away  with  this  difficulty. 
The  calculation  of  the  percentage  of  sugar  in  the  original 
sample  of  urine  is  very  simple.  The  25  c.c.  of  copper  solution 
are  reduced  by  exactly  0.050  gram  of  glucose.  Therefore  the 
volume  of  diluted  urine  drawn  out  of  the  burette  to  effect  the 
reduction  contains  50  mg.  of  sugar. 

When  the  urine  is  diluted  1  to  10,  as  in  the  usual  titration  of 
diabetic  urines,  the  formula  for  calculating  the  percentage  of 
sugar  is  the  following: 

-  X  1000  =  percentage  in  the  original  sample,  wherein  x  is 

the  number  of  cubic  centimeters  of  the  diluted  urine  required 
to  reduce  25  c.c.  of  the  copper  solution. 


176        SELECTED  LABORATORY  TESTS 

"  In  the  use  of  this  method  chloroform  must  not  be  present 
during  the  titration.  If  used  as  a  preservative  in  the  urine  it 
may  be  removed  by  boiling  a  sample  for  a  few  minutes,  and 
then  diluting  to  the  original  volume." 

Methods  for  the  Determination  of  the  Urinary  Acids. — 
Qualitative  Tests.— (1)  Diacetic  Acid  (CH3COCH2COOH).— 
The  simplest  method  for  the  detection  of  acidosis  by  urinary 
examination  is  Gerhardt's  ferric  chloride  reaction  for  diacetic 
acid.  The  test  may  be  performed  as  follows :  To  about  10  c.c. 
of  the  fresh  urine  carefully  add  a  few  drops  of  an  undiluted 
aqueous  solution  of  ferric  chloride,  Liquor  Ferri  Chloridi, 
U.  S.  P.  A  precipitate  of  ferric  phosphate  first  forms,  but 
upon  the  addition  of  a  few  more  drops  is  dissolved.  The  depth 
of  the  Burgundy  red  color  obtained  is  an  index  to  the  quantity 
of  diacetic  acid  present.  I  record  the  intensity  of  the  reaction 
as  follows:     +,++,+  +  +,  or  +  +  +  +.  _ 

Confusion  as  to  the  significance  of  the  test  arises  if  the 
patient  is  taking  sodium  salicylate,  aspirin  or  allied  products. 
This  is  to  a  considerable  extent  avoided  by  vigorously  boiling 
the  urine  after  the  addition  of  the  ferric  chloride,  when  the 
deep  color  markedly  decreases  or  disappears  if  caused  by 
diacetic  acid,  but  remains  the  same  if  caused  by  the  above 
drugs. 

Acetone  (CH3COCH3) .- — The  different  tests  for  acetone  are 
in  reality  tests  for  diacetic  acid.  Legal's  test  is  as  follows: 
A  few  crystals  of  sodium  nitroprusside  are  dissolved  in  5  c.c. 
of  urine,  which  is  then  rendered  alkaline  with  sodium  hydrate. 
A  few  drops  of  glacial  acetic  acid  are  then  slowly  added  and  a 
distinct  purple  color  appears,  which,  if  the  test-tube  is  shaken, 
is  best  seen  in  the  foam. 

Quantitative  Tests. — Ammonia. — The  quantity  of  the  alkali 
— ammonia — in  the  urine  is  a  measure  of  the  effort  of  the 
body  to  counteract  the  acid  poisoning  which  may  be  present. 

To  this  extent  its  estimation  gives  a  more  accurate  idea  of 
the  acid  production  of  the.  body  than  any  other  of  the  urinary 
tests  at  our  disposal,  which  simply  show  the  quantity  of  acid 
leaving  the  body.  The  test,  however,  becomes  of  less  value 
as  soon  as  extraneous  alkali  is  administered,  because  under 
such  conditions  the  ingested  alkali  is  used  by  the  body  in 


EXAMINATION  OF  URINE,  BLOOD,  EXPIRED  AIR     111 

preference  to  ammonia.  The  normal  amount  of  ammonia 
in  the  urine  varies  between  0.5  to  1  gram,  and  the  ratio 
between  the  ammonia-nitrogen  to  the  total  nitrogen  in  the 
urine  is  fairly  constant  at  1  to  25  (4  per  cent.).  In  severe 
diabetes  the  ammonia  may  gradually  increase,  and  in  Case 
No.  344  it  amounted  to  8  grams  in  one  day. 

Ronchese-Malfatti  Method for  the  Determination  of  Ammonia. 
— (a)  To  25  c.c.  of  urine  in  a  200  c.c.  Erlenmeyer  flask, 
add  about  25  c.c.  of  distilled  water,  about  10  grams  (1  to  2 
teaspoonfuls)  of  powdered  potassium  oxalate,  and  a  few  drops 
of  indicator  (phenolphthalein).  Shake  a  few  times  to  dissolve 
the  oxalate,  then  titrate  with  one-tenth  normal  sodium 
hydroxide  until  the  first  faint  pink  color  is  permanent. 

(b)  Take  5  c.c.  of  commercial  formalin  solution  in  a  test- 
tube,  add  a  few  drops  of  phenolphthalein  indicator,  and  then 
titrate  with  one-tenth  normal  sodium  hydroxide  until  a  faint 
pink  is  obtained. 

(c)  Add  this  neutralized  formalin  to  the  urine,  which  has 
just  been  titrated,  and  titrate  again  with  one-tenth  normal 
sodium  hydroxide  until  the  previous  pink  is  again  obtained. 

(Calculation:  The  number  of  cubic  centimeters  of  one- 
tenth  normal  alkali  used  in  titration  (c)  multiplied  by  0.0017 
gives  the  number  of  grams  of  ammonia  in  25  c.c.  of  urine.) 

No  account  need  be  taken  of  the  amount  of  sodium 
hydroxide  used  in  titrations  (a)  and  (b). 

The  method  depends  upon  the  fact  that  formalin  combines 
with  free  NH3  and  forms  hexamethylenetetramin.  The 
ammonia  is  liberated  from  its  salts  by  means  of  NaOH. 

Nitrogen. — The  Kjeldahl  method  is  that  usually  employed 
for  determining  the  nitrogen,  and  a  modification  of  it  has 
served  me  best.1  However,  improvements  in  the  method  are 
constantly  taking  place,  and  time  will  always  be  saved  by 
adopting  the  most  recent  methods. 

Sodium  Chloride. — The  method  which  I  employ  for  deter- 
mining the  sodium  chloride  is  Volhard's  quantitative 
method.2 

1  Joslin:  The  Treatment  of  Diabetes  Mellitus,  2d  edition,  Lea  & 
Febiger,  1917,  p.  10s. 

2  Loc.  cit.,  p.  201. 

12 


178  SELECTED  LABORATORY  TESTS 


THE  EXAMINATION  OF  THE  BLOOD. 

Blood  Sugar. — The  Lewis-Benedict  method  is  the  one  upon 
which  I  now  depend,  with  the  modification  of  Myers  and 
Bailey.1  Recently  I  have  been  much  impressed  with  the 
blood-sugar  method  recommended  by  Epstein.2  This  is  a 
method  particularly  adapted  to  the  practising  physician,  for 
the  apparatus  necessary  for  its  performance  can  be  readily 
obtained  and  the  technic  easily  learned.  The  directions  for 
the  test  come  with  the  apparatus.3  I  am  glad  to  insert  a  series 
of  ten  consecutive  determinations  obtained  with  this  method 
by  Miss  Harriet  Amory,  and  place  alongside  them  for  com- 
parison the  results  obtained  with  the  Lewis-Benedict  method 
by  Miss  Evelyn  Warren,  who  has  had  much  experience  writh  it. 

Table  33. — Comparative  Blood-sugar  Determinations. 


(Performed  by  Evelyn  Warren  and  Harriet  Amory 

with  the  Lewis- 

Benedict  and  Epstein  Methods.) 

Benedict-Lewis. 

Epstein. 

0.23 

0.25 

0.19 

0.24 

0.10 

0.15 

0.34 

0.34 

0.20 

0.23 

0.22 

0.22 

0.23 

0.26 

0.09 

0.12 

0.21 

0.24 

0.10 

0.10 

Wishart  Method  for  Detection  of  Acetone  in  the  Blood. — 
The  blood  is  drawn  into  a  syringe  or  tube  containing  a  few 
crystals  of  potassium  oxalate,  then  centrifuged  for  five 
minutes  at  medium  speed.  The  test  is  made  on  the  plasma 
with  as  little  delay  as  possible,  as  there  is  liable  to  be  some 
loss  of  acetone  on  standing. 

For  a  small  quantity  of  plasma  (0.5  c.c.  or  more)  add  solid 
ammonium  sulphate  until  plasma  is  thoroughly  saturated 
and  protein  precipitated;  then  add  two  or  three  drops  of  a 
freshly  made  5  per  cent,  solution  of  sodium  nitroprusside  and 

1  Loc.  cit ,  p.  203. 

2  Epstein:  Jour.  Am.  Med.  Assn.,  1914,  lxiii,  p.  1667. 

3  Purchased  from  E.  Leitz,  New  York. 


EXAMINATION  OF   URINE,  BLOOD,  EXPIRED  AIR     179 

a  few  drops  of  concentrated  ammonium  hydrate.  If  the  test 
is  positive,  in  from  one  to  ten  minutes  a  color  develops  which 
runs  all  the  way  from  a  pale  lavender  to  that  of  a  deep 
permanganate  hue,  in  this  way  indicating  whether  much  or 
little  acetone  is  present.  This  is  an  adaptation  to  the  plasma 
of  the  Rothera  nitroprusside  reaction  as  ordinarily  used  for 
urine.    It  is  said  to  be  sensitive  to  1  part  in  20,000. 

EXAMINATION  OF  THE  EXPIRED  AIR  FOR  CARBON 
DIOXIDE. 

A  knowledge  of  the  carbon  dioxide  in  the  alveolar  air  is  of 
greatest  assistance  in  determining  the  presence  or  absence  of 
acid  poisoning.  Two  methods  are  available,  the  Fridericia 
method1  and  Marriott's  method.2  Both  methods  are  excel- 
lent, but  the  Marriott  method  is  rather  more  practicable  for 
the  practising  physician.  The  Fridericia  apparatus  can  be 
obtained  from  Emil  Greiner,  55  Fulton  Street,  New  York, 
and  the  apparatus  for  the  Marriott  method,  with  the 
description  of  the  technic  for  its  use,  from  Hynson,  Wescott 
&  Company,  Baltimore,  Md.  The  alveolar  air  collected  by 
the  Fridericia  method  is  of  a  carbon  dioxide  tension  from  10 
to  20  per  cent,  lower  than  that  collected  by  the  Marriott 
method. 

Normally,  the  carbon  dioxide  tension  of  the  alveolar  air 
varies  between  38  and  45  mm.  mercury,  5.3  to  6.3  per  cent. 
If  abnormal  acids  are  present  in  the  blood,  these  displace  a 
proportionate  amount  of  carbon-xlioxide,  and  as  the  carbon 
dioxide  tension  in  the  alveolar  air  bears  a  direct  relation  to 
that  in  the  blood,  it  is  evident  that  the  carbon  dioxide  in  the 
alveolar  air  will  vary  likewise.  A  low  carbon  dioxide  tension 
of  the  alveolar  air  therefore  indicates  an  acidosis.  If  the 
carbon  dioxide  tension  lies  between  38  and  32  mm.  mercury 
a  slight  acidosis  is  present,  between  32  and  28  a  moderate 
acidosis,  and  if  it  falls  below  25  mm.  mercury  the  acidosis  is 
extreme.  The  lowest  value  with  recovery  in  my  group  of 
cases  has  been  14  and  the  lowest  obtained  in  the  series  was 
9,  and  that  occurred  in  a  patient  in  coma. 

1  Loc.  cit.,  p.  233.  2  Loc.  cit.,  p.  237, 


INDEX. 


Acetone  in  blood,  Wishart  method 
for  detection  of,  178 
in  urine,  test  for,  176 
Acidosis    (acid    intoxication,   acid 
poisoning),  103 
carbon  dioxide  in  alveolar  air  as 

measure  of,  179 
commonest  enemy  of  diabetic,  32 
danger  of,  arising  from  fat,  61 
dependence  on  fat,  77 
prevention  of,  32 

by  withdrawal  of  fat,  77 
rules  for  treatment  of,  104 
tests  for,  qualitative,  176 
quantitative,  176 
Agar  agar,  for  constipation,  118 

jelly,  132 
Albumin,  tests  for,  heat  test,  167 
nitric  acid  test,  167 
in  urine,  167 
Alcohol,  caloric  value  of,  42 

in  diabetes,  77 
Alveolar  air,  carbon  dioxide  ten- 
sion, 179 
Fridericia  method,  179 
Marriott  method,  179 
Ammonia,    Ronchese-Malfatti 
method  for  determination  of, 
177 
in  urine,  176 
Anger  dangerous  for  diabetic,  49 
Arithmetic,  diabetic,  34 
Asparagus,  soup  variety,  134 
Automobile,  fuel  (food)  of,  41 
Avoirdupois  system,  34 

B 

Bacon,  loss  of  weight  during  cook- 
ing, 60 


Bananas,  analyses  of,  147 
carbohydrate  in,  40,  51,  71 
weight  of,  36 
Bavarian  cream  (diabetic),  132 
Benedict's  test,  qualitative,  169 
illustration,  37 
solution  for,  168 
quantitative,  170 
apparatus  required  for,  171 
per  cent,  sugar,  174 
solution  for,  171 
Berries,  analyses  of  fresh,  146 
Beverages,  analyses  of,   alcoholic, 
162,  164 
non-alcoholic,  154 
Blood,  acetone  in,  178 

sugar  in,  178 
Boiled  dinner,  134 
Bottles,  percolator,  45 
Bran,  122 

muffins  for  constipation,  US,  130 
for  diabetics,  130 
Brandy,  78 

Bread,  analyses  of,  153 
bran,  122 

"rarbohydrate    content,    40,    72, 
122 
casein,  123 

coarse,  carbohydrate  in,  72 
gluten,  123 

carbohydrate  in,  72 
light  (French),  123 
substitutes  for,  121 
undesirability  of  giving,  72 
Broths,  calories  negligible,  91 
gelatin  in,  74 
nutritive  value  of,  74 
Butter,  61 

Maitre  d'Hotel,  139 
toleration  for,  76 
Butterine,  content  for,  76 
Buttermilk,  60 


1S2 


INDEX 


Cabbage,   raw,    for   constipation, 

119 
Caloric  needs  of  advancing  age,  58 
by  children,  57 
in  diabetes,  32,  66,  100 
at  hard  work,  57 
at  light  work,  57 
at  moderate  work,  57 
at  rest,  57 

in  sedentary  occupations,  57 
in  walking,  additional  calories 
required,  100 
Calorie,  definition  of,  32,  56 

the  food  measure,  41 
Candy,  danger  in  candy  habit,  19 
rules  broken,  fasting  required,  95 
Cannon,  experiments  of,  47 
Carbohydrate,  addition  of  5  grams, 
48 
content  of  foods,  24,  38,  53 
estimation  of,  in  clinical  work, 

56 
in  normal  diet,  51 
tolerance  for,  apparent  tolerance, 
93 
determination  of,  93 
remarkable  increase  in,  81 
in  vegetables,  51,  66 
where  found,  29,  40,  51 
Carbon  dioxide  tension  of  alveolar 

air,  179 
Cellulose,  52,  122 
Cheese,  61 

Children,  food  requirements  of,  41 
heights  of,  107 

school  children  and  diabetes,  19 
weights  of,  107 
Chittenden,  low  protein  diet,  73 
suggests   excess    of    food    detri- 
mental of  health,  58 
Chocolate,  analyses  of,  154 
Clams,  composition  of,  74 
Cocoa,  cracked,  131 
cocoa  whip,  139 
Coffee  Spanish  cream,  139 
Coma,  diabetic,  103 
Condiments,  analyses  of,  147 
Constipation,  treatment  of,  118 
exercises  for,  118 
potato  skins  counteract,  70 
raw  cabbage,  119 
sawing  wood  warded  off,  119 


Crackers,  carbohydrate  in,  72 
Cream,  61 

puff  (Lister),  139 

whipped,     Litchfield's     method, 
125 
Crisco,  content  of,  76 


Dairy  products,  analyses  of,   149 
Diabetes,  candidate  for,  19 

causes  of,  derangement  of  func- 
tions of  pancreas,  17 
lack  of  exercise,  18 
overfeeding,  19 
remediable,  23 
strenuous  life,  19 
chronic,  17 
definition  of,  20,  30 
discovery  of,  easily  made,  20 
experimentally  produced,  IS 
heredity  and,  19 

favorable  influences  of,  19 
improvement  in,  20 
incidence  of,  in  Boston,  v 
increasing,  19 
in  United  States,  v 
infectious  diseases  and,  19 
measures  for  decrease  of,  20 
mild,  definition,  82 
moderate,  definition,  82 
not  contagious,  17 
painless,  17 

predisposition  to,  19,  47 
serious  in  past,  26 
severe,  definition,  82 
symptoms,  annoying  vanish,  20 
treatment  of,  description,  30 
diet  in,  17 
drugs  in,  17 
early,  21 

illustrations  of  cases  success- 
fully treated,  80,  91 
improvement  in,  26,  27 
attributed  to,  27 
author's  series,  27 
Massachusetts  General  Hos- 
pital, 26 
mild  cases,  22 
moderately  severe  cases,  80 
need  of  further  improvement 

in,  28 
neglected,  21 


INDEX 


183 


Diabetes,  treatment  of,  object  of,  SO 
severe  cases,  80 
susceptibility  to,  17 
untreated,    makes    food    spend- 
thrift, 23 
Diabetic,  caloric  needs  of,  66 
commonest  enemy  of,  32 
hygiene  for,  47 
knowledge  essential  for,  29 
questions  and  answers  for,  29 
rules  for,  66 
weight  of,  32 
why  hungry,  30 
why  thirsty,  30 
Diacetic  acid,  test  for,  176 
Diarrhea,  118 

Diet,   caloric  value  of,   source  of 
error  in  calculating,  59 
carbohydrate-free,  51 
computation  of,  42 
diabetic,  carbohydrate  iri,  esti- 
mation of,  66 
essentials  of,  54 
fat  in,  75 
protein  in,  73 
estimation  of,  weights  and  meas- 
ures employed,  34,  56 
"    examination  of,  information  ob- 
tained by,  45 
expensive    with   untreated   dia- 
betic, 110 
normal,  51,  57 

and  diabetic  compared,  65 
fat  in,  in  northern  climates,  54 

in  the  tropics,  54 
proportion    of    carbohydrate, 

protein  and  fat,  58 
protein  in,  53,  58 
tables  of,  143 
Dietetic  rules  and  hints,  101 
suggestions,  recipes  and  menus, 
121 
Diversion,  desirable,  49 
Doctor,  visits  to,  efficiency  in,  45 
Drinking  glass,  capacity  of,  35 
Dropsy,  diabetes  and,  79,  108 
Druggists,  vi,  165 
Drugs   in   treatment   of  diabetes, 
17,  120 


Eggs,  analysis  of,  151 
by  law  weigh,  59 


Eggs,  thirteen  for  breakfast,  110 
weight  of,  36 

maximum  and  minimum,  60 
white  of,  content,  54 
yolk  of,  content,  54 
Eskimos,  diet  largely  of  fat,  75 
Excitement,  effect  of,  on  urine,  47 
Exercise,  effect  of,  on  fat  diabetics, 
47 
examples,  48,  49 
lack  of,  18 


Fast  days,  weekly,  99 
thirty-one  days,  41 
Fasting,  87 

avoidance  in  the  old,  91 
Dr.  Randall's  plan,  99 
examples  of,  87 
intermittent,  92 
preparation  for,  87 
relief  to  patients,  90 
required  because  rules  broken,  95 
simplest  means  of  freeing  urine 
of  sugar,  85 
Fat,    administration   of,    slow   in- 
crease in  presence  of  obesity, 
97 
a  concentrated  food,  59 
danger  to  diabetic,  77 
an  expensive  food,  59 
how  much  should  diabetics  eat? 

75 
in  normal  diet,  59 
tolerance  for,  determination    of, 
~      96 
by  signs  of  acidosis,  96 
where  found,  examples  of,  29,  40, 
54 
Fehling's  test,  qualitative,  169 
Fermentation  test,  170 
Fish,  analyses  of,  fresh,  150 

preserved  and  canned,   150 
composition  of,  73 
preserved,  composition  of,  74 
Flour,  analyses  of,  152 
Food,  carbohydrate,  29,  40 
content  of,  24,  53 
total  calories,  39 
classification  of,  29 
conservation  of,  model  in,  66 
excess,  detrimental  to  health,  58 


184 


INDEX 


Food,  fat,  29   40 

total  calories,  39 
measure,  41 
needs  of  diabetic,  32 
protein,  29,  40 

total  calories,  39 
requirements,  29,  55 

accurate  calculation  of,  55 

of  children,  41 

of  old  people,  41 

in  sedentery  occupations,  57 
spendthrift  of,  23 
stored  up  in  body,  41 
values,  40,  55 

absurdity     of     reckoning     to 
fraction  of  gram,  64 

errors  in,  63,  64 
weighing,  method  of,  34,  56,  72 
Fruit,  analyses  of,  canned,  147 

dried,  147 

fresh,  146 
carbohydrate  in,  38,  40,  71 
Furunculosis  in  diabetes,  116 


G 


Galactan,  71 

Garden  for  diabetic  patients,  134 

Gelatin,  analysis  of,  151 

in  broths,  74 

protein  in,  126 
Gin,  78 

Glycogen,  animal  starch,  41,  51 
Grape  fruit,  analyses  of,  147 


H 

Height  of  children,  107 
Hemicelluloses,  71 
Hepco  cakes,  130 
Horseradish,  134 
sauce,  138 


Ice  cream  (diabetic),  132 

Indian,  emulation  of,  by  diabetic, 

106 
Infectious  diseases,  diabetes  and, 

19 
Insurance,  106 


Irish  moss,  129 

Islands    of    Langerhans,    diabetes 
and,  18 


Jelly,  agar  agar,  132 
coffee  whip,  139 
cracked  cocoa  whip,  139 
lemon,  131 

rhubarb  with  meringue,  139 
wine,  139 


Koumiss,  carbohydrate  in,  72 


Lard,  content  of,  76 
Lemon  jelly  (diabetic),  131 
Lettuce,  carbohydrate  in,  39 
Lime    water,    preparation    of,    for 

teeth,  114 
Liquids  in  diabetes,  78 
Lister's  diabetic  flour,  126 
Liver,  animal  starch  in,  51 

composition  of,  73 
Lobster,  carbohydrate  in,  43 


M 

Margarine,  nut,  content  of,  76 
Meals,  analyses  of,  152 
Meat,  analyses  of,  150 
canned  extracts  of,  75 
composition  of,  73 
protein  in,   percentage   falls  as 
fat  rises,  74 
Mental  attitude,  change  in  gratify- 
ing, 50 
relaxation,  47 
Menus,  inexpensive,  140 
picnic  lunches,  141 
severe  diabetic,  135 
Metric  system,  34 
Milk  and  milk  products,  analyses 
of,  149 
graphic  table,  61 
carbohydrate  in,  43,  72 
fermented,  125 
food  value  of  glass  of,  60 


INDEX 


185 


Milk,  protein  in,  61 
skimmed,  60 
substitutes  for,  123 
sugar-free,  124 

Miscellaneous  analyses,  154 


N 


Nitrogen  in  urine,  determination 

of,  177 
Note  book,  46 

for  reference,  46 
treatment  systematized  by,  46 
Nut  preparations,  analyses  of,  148 
Nuts,  analyses  of,  148 
carbohydrate  in,  38,  71 


Oatmeal,  carbohydrate  in,  72 

food  value  for  dry  weight,  40 
Oil,  content  of,  76 

corn,  77 

cotton-seed,  77 

cough  medicine  for  diabetics,  76 

as  lunch  for  diabetics,  76 

peanut,  77 

relieves  symptoms  of  hyperacid 
stomach,  77 
Oleo,  content  of,  76 
Olives,  green,  carbohydrate  in,  71 

ripe,  carbohydrate  in,  71 
Oranges,  analyses  of,  147 

carbohydrate  in,  71 
Outlook,  diabetes  and,  23 

early  detection  makes  favor- 
able, 23 
Overfeeding,  19 
Oyster  crackers,  weight  of,  36 
Oysters,  composition  of,  74 

food  value,  40 


Pancreas,  diabetes  and,  17 

increase  of  power  to  assimilate 

carbohydrate,  20 
internal  secretion  of,  18 

Pastes,  analyses  of,  154 

Pastry,  analyses  of,  153 

Patients,  intelligent,  46 


Pedometers,  47 

Pentosan,  71 

Physician's  office,  visit  to,  45 

Pickles,  analyses  of,  147 

sour,  134 
Picnic  lunches,  141 
Potatoes,  baked,  desirability  of,  70 

carbohydrate  in,  40,  70 
Protein,  advantage  of,  to  the  dia- 
betic, 96 

Cannon's     investigations      con- 
cerning, 58 

estimation  of,  in  clinical  work,  56 

in  gelatin,  126 

quantity  in  normal  diet,  58 

sugar  formed  from,  61 

tolerance  for,  determination  of, 
94 

vegetable,  73 

where  found,  examples  of,  29,  40, 
54 


Questions  and  answers  for  dia- 
betic patients,  29 


R 


Rations,  furnished  to  soldiers,  55 
in       German       prisoner-of-war 
camps,  55 
Recipes,  diabetic,  125 
Responsibility,   heavy,   should   be 
avoided,  49 
rests  upon  patient,  21 
Rest7  essential,  49 
Rum,  78 


Saccharin,  125 

Salt  (sodium  chloride),  78 

harmful  effects  of,  75,  79 

in  urine,  determination  of,  177 
Sauce,  custard,  139 

grated  horseradish,  138 

Maitre  d'Hotel  butter,  139 

mint,  138 

parsley,  138 

tomato,  138 
Sea  moss,  129 
Seasoning,  134 


186 


INDEX 


Shell-fish,    agreeable    addition    to 
diet,  74 
analyses  of,  151 
Shredded  wheat  biscuit,  weight  of. 

34,36 
Skin,  care  of,  116 

dry   because   of   withdrawal   of 

salt,  78 
infections  of,  1 16 
Soldiers,  rations  of,  55 
Solomon's  soliloquy,  46 
Soup,  analyses  of,  canned,  151 
home-made,  151 
spinach,  140 
Soy  bean,  123 

baked,  recipe,  129 
Squab,  134 
Starch,  40 

in  normal  diet,  51 
in  various  foods,  40 
String  beans,  carbohydrate  in,  39, 

67 
Sugar,  barrel  of,  lost  in  urine,  22, 
111,  also  frontispiece, 
consumption  of,  in  United  States 

19 
formed  from  protein,  61 
lost  in  urine,  mild  diabetic,  22 
moderately  severe  diabetic, 

111 
severe  diabetic,  111 
lump  of,  weight,  34,  36 
in  normal  diet,  51 
overfeeding  of,  19 
reappearance  of,  97 

failure  to  grapple  with,  98 
examples  of,  98,  99 
in  relation  to  sugar  in  urine,  20, 

43,  167 
removal  from  urine,  31 
tests  for,  qualitative,  168 
quantitative,  170 
Sugar-free,  variable  period  of  time 
required  to  become  so,  92 
without  fasting,  88 
Sundays,  diabetic,  99 
Sweet  taste,  49 
Sweetbread,  17 


Tablespoon,  capacity  of,  35 
Teaspoon,  capacity  of,  35 


Teeth,  care  of,  113 
Toast,  carbohydrate  in,  72 
Treatment,  early,  21 

of  mild  cases,  22 

neglected,  21 


U 


Uneeda  biscuit,  weight  of,  36 
Urine,  appearance  of  sugar  follow- 
ing football  game,  83 
collection  of,  45,  166 
examination  of,  166 

information  obtained  by,  45 
to  be  made  on  each  birthday, 
165 
fermentation  of,  45 
following  emotional  excitement, 

47 
not  sugar-free,  patient  growing 

worse,  21 
percentage  of  sugar  in,  30 
reaction  of,  166 
removal  of  sugar  from,  31 
specific  gravity  of,  166 
Utensils  essential  for  the  diabetic, 
62 


Vegetables,  analyses   of  canned, 
145 
fresh,  144 
camouflage,  67 
carbohydrate  in,   38 

5  per  cent,  group,  38,  42,  51 
10  per  cent,  group,  38,  51 
15  per  cent,  group,  38,  51 
20  per  cent,  group,  38,  51 
loss  in  cooking,  67,  68 
5  per  cent.,  computation  in  diet, 
42 
not  necessary  to  weigh  in 

mild  cases,  67 
saucerful  of,  39 
total  carbohydrate  content 
fc  eaten    in    twenty-four 
hours,  67 
thrice  cooked,  67,  133 
washed,  analyses  of,  69 
Voit  standard,  59 


INDEX 


187 


w 

Weight,  106 

body,  how  taken,  46 

changes  in,  during  treatment,  10S 

of  children,  107 

of  diabetic  patients,  32 

loss  by  fasting,  78 

of  normal  individuals,  106 


Weights  and  measures,  34,  56 
avoirdupois  system,  34 
metric  system,  34 

Whey,  61 

Whisky,  78 


Zwieback,  carbohydrate  in,  72 


COLUMBIA   UNIVERSITY    LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
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the  Librarian  in  charge. 


DATE  BORROWED 


DATE  DUE  DATE  BORROWED      j  DATE  DUE 


MAY  2  2 197f 


C2B  (747J  MtOO 


Joslin 


Diabetic  manual 


% 


RC660 
J782 

1910 


